The Importance of Health Care Policy Priorities in

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The Importance of Health Care Policy Priorities in Mississippi: Public Opinion vs. Legislators’ Opinions*

Doug Goodman David A. Breaux Barbara Patrick Stephen D. Shaffer

Prepared for presentation at the 2005 annual meeting of the Southern Political Science Association meeting, January 6-8, New Orleans, LA.

* We would like to thank our graduate assistant, Hilary B. Gresham, who offered valuable suggestions on an earlier draft of this paper.


One of the most fundamental questions of concern to both political scientists and public administrators is the quality of American democracy. This question is often addressed from the theoretical perspective of “representation,” as public officials are studied to assess whether they provide descriptive representation of the public’s demographic characteristics or their political attitudes, or to determine whether officials “act for” their constituents (Pitkin, 1967). As we start the 21st century, this issue of the quality of American representational democracy becomes an even more vital concern. American foreign policy in the new era of worldwide terrorism places a greater emphasis on promoting democracy around the world, arguing that democratic processes reduce the inhumane conditions that give rise to terrorism. It is therefore timely that we reexamine the quality of American representational democracy in this new era of globalization. We address this fundamental question by focusing on a state and an issue that is of vital interest to Americans and to the world community more generally. As American leaders preach to the world about the importance of liberty and democracy to humanity, the United States itself until forty years ago denied the benefits of such human rights to a sizable portion of its population. V.O. Key’s (1949) classic Southern Politics details the extraordinary lengths to which white political leaders in the eleven southern states went to deny African Americans such basic rights of citizenship as voting. Mississippi embodied the essence of the South, offering its governor Fielding Wright as the Vice Presidential running mate of Strom Thurmond on the States’ Rights Party in 1948, and establishing a state Sovereignty Commission in the 1950s that became a model for other southern states’ efforts to resist any challenge to the culture of racial segregation (Katagiri, 2001). It is therefore quite interesting to revisit Mississippi’s political culture

2 today to assess how well the political system represents the interests of “all” of its citizens. We focus on assessing the quality of representation on the vital issue of health care. Historically speaking, this is a relatively new concern of the federal government, as federal Medicaid and Medicare were not established until the 1960s. Yet with the growing costs of health care in the face of an aging population and rising public demands for care, this issue has become one of the top two domestic concerns of Americans nationally, rivaling perennial concerns over the public educational system. In Mississippi as well, statewide polls have shown rising public concern over the health care issue, elevating it as second only to education in importance to the public (Shaffer, Jackreece, and Horne, 1999: 15). Health care has became even more salient to Mississippians with the election of conservative Republican Haley Barbour as governor in 2003. Facing a massive budget deficit in his first year in office, Barbour convinced the legislature to reduce the growth of the state Medicaid budget by shifting 65,000 poverty level and/or disabled elderly from the state/federal Medicaid program to the fully federally-funded Medicare program. A storm of public protest ensued, as advocates for the elderly charged that many of those recipients would receive less generous benefits under Medicare (Starkville Daily News, 2004; The Clarion Ledger, 2004).


Previous Studies on the Quality of Representation in America

The quality of representation in America was first empirically addressed at the national level in the classic “Constituency Influence in Congress” APSR article by Miller and Stokes (1963). They pioneered a model having four variables with the constituency’s attitude on public issues constituting the earliest independent variable, the congressional representative’s roll call votes being the dependent variable, and intervening variables being the representative’s attitude on the issue and his or her’s perception of their constituency’s opinion on the issue. They concluded that the linkage between constituency opinions and representatives’ roll call behavior in their study of the 1958 Congress was strongest for civil rights issues, as not only did congress members tend to share their constituents’ attitudes on this issue, but to also accurately perceive what their constituents’ opinions were on such salient racial concerns. In a reanalysis of their data, Erikson (1978) added that relationships between constituency opinions and congressional roll call votes also existed on social welfare and foreign policy issues, once the analysis was corrected for measurement error associated with the small sample sizes of citizens in each congressional district. He also added that the major cause of the mass-elite linkage on social welfare issues was that congress members tended to share the same attitudes as their constituents on these issues, and that they tended to merely vote their own attitudes. Since medical care was only one of four issues included in their social welfare scale, it is important that we reexamine whether today’s representatives share the public’s views on more contemporary health care concerns.

4 Subsequent national studies also found some correspondence between public preferences on issues and congress members’ own issue attitudes or the public policies enacted into law. Employing CBS/New York Times national surveys from 1970-1982 of the public and of congress members, Frankovic and Epstein (1979, cited in Erikson and Tedin, 2003) found few differences between the average citizen and the average congress member, even on the issue of national health insurance. Examining national opinion polls from 1960 through 1974, as well as congressional actions, Monroe (1979) examined public-congressional consistency on whether public policies remained the same or changed. Though he found mass-elite consistency 64% of the time, somewhat greater than the chance value of 50%, the American public and Congress agreed only 57% of the time on social welfare issues. Examining national polls and policy changes from 1935 through 1979, Page and Shapiro (1983) found that when national public policy changed, it was nearly twice as likely to change in the direction of public opinion shifts than to change in the opposite direction. Page and Shapiro also found mass-elite congruence greater on “salient” issues frequently asked in national polls or eliciting few don’t know responses. However, they did not disaggregate public policy into different types of issues to permit a more specific focus on health care or social welfare types of issues. Fewer studies have examined the quality of representation at the state level, even though this is a vital level of government in our federalist nation, particularly on domestic issues. Using a survey based measure of the public’s ideological self-identification in 47 states, Wright, Erikson and McIver (1987) found public opinion more important than state urbanism, education, and income levels in affecting eight specific state public policies, including Medicaid’s scope. Employing national samples of the public and state

5 legislators, state bureaucrats, and county political party leaders, Uslaner and Weber (1983) found that legislators tended to be closer in policy attitudes to the public than were the two other elite groups, since both tended to be more centrist in views. Unfortunately, none of the ten state and local issues they examined pertained to health care concerns. Uslaner and Webb also found a partisan dimension to the representation question. While Democratic elites tended to be more liberal than the masses and Republican elites more conservative than average citizens, Democratic elites were closer to the public than were Republican elites. A number of studies assessing descriptive representation in terms of attitudes toward public policies have uncovered a partisan dimension, where elites of various types of one of the major parties have been closer in attitudes to the average American than were elites of the other major party. The conventional wisdom is that Republican elites tend to be more out-of-touch with average citizens than are Democratic elites. McCloskey, Hoffmann, and O’Hara’s (1960) classic APSR article, “Issue Conflict and Consensus among Party Leaders and Followers,” pioneered this theory by comparing the national party convention delegates (many of whom were public officials and state party leaders) with a national sample of citizens whose party identifications were ascertained. While Democratic elites in the late 1950s were only slightly more liberal on numerous issues than Democrats in the public, Republican elites were consistently more conservative than the GOP citizenry party and therefore representative of the views of only a minority of all voters. Subsequent studies conducted in the 1960s also found a significant conservative bias among Republican elites compared to GOP masses, and greater congruency between the Democratic elites and masses, when defining elites as

6 campaign activists and Americans who were politically active in other ways (Nexon, 1971; Verba and Nie, 1972). Regrettably, health care was not one of the 24 issues examined by McCloskey et al or one of the issues focused on by Verba and Nie, though it was one of four items in Nexon’s social welfare scale. Increased activism by liberal ideologues within the Democratic Party, associated with the anti-war and civil rights movements of the 1960s and the George McGovern presidential bid of 1972, produced findings suggesting that Democratic elites had now become too ideologically extreme for average voters—though in the opposite “liberal” direction. Ladd and Hadley (1973) found that by the late 1960s, though both party’s college educated supporters were more ideologically extreme than other party identifiers in national opinion polls, college Democrats were much more liberal than other Democrats. Kirkpatrick (1975) found that Democratic national convention delegates in 1972 were much more liberal than Democratic identifiers in the public, while Republican elites were much more consistent with the views of average citizens. Surveying the attitudes of congressional candidates and average Americans in 1970, Backstrom (1977) found Republican elites to be the party better reflecting the views of their partisans in the public, while Democratic elites were significantly more liberal than the Democratic masses. Finally, examining campaign activists in national opinion polls, Shaffer (1980) found that after 1966, Democratic elites were generally more liberal than their party’s inactive citizens on domestic economic, civil rights, and civil liberty issues, while fewer differences existed between Republican masses and elites. Unfortunately, health care was not one of the six issues asked of both congressional candidates and the public in the Backstrom study, nor was it one of the 21 issues and social groups examined by

7 Kirkpatrick, though it was one of the numerous issues briefly examined by Shaffer and Ladd and Hadley. It wasn’t until the 1990s and the emergence of a competitive two party system in the South that the partisan dimension to representation in that region was explored. Comparing county party organization members to party identifiers in statewide opinion polls in Alabama and Mississippi in the early 1990s, Breaux, Shaffer, and Cotter (1998) found support for the conventional wisdom, as Republican elites were consistently more conservative than the GOP masses on policy issues, while Democratic party officials were much closer ideologically to their party’s rank and file. Examining the same party organization data for the entire region and supplementing it with a regional sample of convention delegates and a regionwide public opinion poll, Maggiotto and Wekkin (2000) found that both southern parties exhibited some representation problems, as not only were Republican elites generally more conservative than Republican masses, but Democratic elites were generally more liberal than Democratic masses. Each study included only one health care issue item, whose patterns reflected those found for the other issues examined. By 2001, Patrick, Shaffer, Cotter, and Fisher (2004) found that organization members of both parties in Alabama and Mississippi had shifted somewhat towards the ideological extremes over the previous decade. Also comparing elites and masses in the entire South, they found that while Republican elites continued to be farther from the issue views of average southerners than were Democrats, Democratic elites were also exhibiting a growing problem of being more liberal than Democratic identifiers in the southern population. Regrettably, health care was not one of the issues included in

8 this study, and all three of these studies focused on political party activists rather than public officials.

Methodology of Our Study
Our in-depth study of representation on the salient issue of health care in the critical southern state of Mississippi relied on a telephone sample of adults statewide, and a mail survey of the entire population of state legislators. The telephone survey of the public was conducted with a state-of-the-art CATI system by the Social Science Research Center at Mississippi State University (MSU) under the direction of one of this paper’s authors. Five hundred twenty-three adult Mississippi residents were interviewed from April 5-21, 2004, yielding a response rate of 48% and a sample error plus or minus 4.4%. To achieve a representative sample, since not all groups were equally likely to own telephones, this dataset was weighted by key demographic characteristics. The survey of state legislators was conducted by three of the authors of this paper, and it was funded by a grant from the Social Science Research Center and the Bower Foundation. It consisted of a two wave mail survey and a third wave telephone survey, conducted from March 31 through June 1, 2004. Eighty-nine of the 122 state house members and 52 state senators completed the survey for a response rate of 51%. Because of a slightly greater tendency of white lawmakers and Republicans to complete the surveys, we weighted that dataset by race so that the weighted legislator sample was within 1% of the actual legislature in terms of race, party, and gender groupings.

9 Both surveys included seven questions asking respondents to rate the importance of specific health related activities and services in terms of being Very Important, Important, Somewhat Important, or Not Important. These items were:

How important is public education to encourage good nutrition and physical activity? How important is preventive health care? How important is recruiting and retaining doctors in Mississippi? How important is improving the health status of minority groups in Mississippi? How important is providing healthcare services for children whose families cannot afford health insurance? How important is providing healthcare services for adults who cannot afford healthcare insurance?

The reliability of these seven items was tested by calculating the Alpha coefficients. For the mass survey, the Alpha for all seven items was a sizable .7952. The third item pertaining to recruiting and retaining doctors was not as highly correlated with the other six items as those six items were intercorrelated with each other, but dropping this item from the Alpha scale analysis increased the Alpha coefficient only slightly to .7998. For the elite survey, the Alpha for all seven items was a significant .6957. In this case, the recruiting and retaining doctors item was essentially unrelated to the other six items, so dropping this item from the Alpha scale analysis increased the Alpha coefficient to a more impressive .7460. We are satisfied that all of these items are reliable indicators of the public’s views toward the importance of health care programs. However, we recognize that the public and particularly the legislators may view health care from two

10 or more perspectives—one focusing on the consumer (themselves), and one focusing on the providers (such as doctors and nurses). Therefore, we will list the provider item last in our list of seven health care programs in all tables and discussion.

We also conducted a construct or criterion validity test by relating our indicators of health care priorities to a well established indicator asking average citizens their preferred governmental spending priorities. They were read the following statement: “Now I'm going to ask you about some issues facing state and local government in Mississippi. As you know, most of the money government spends comes from the taxes you and others pay. For each of the following, please tell me whether you think state and local government in Mississippi should be spending more, less, or about the same as now.” Among the ten programs asked about was: “health care and hospitals.” This question was recoded so that responses ranged from a low of 1 for a desire to spend less to a high of 3 for a desire to spend more. The seven health care priorities were coded to range from a low of 0 for Not Important to a high of 3 for Very Important.

Our seven indicators of health care priorities exhibit considerable validity. Each of these items is significantly related to spending preferences on health care and hospitals. As average Mississippians rate a health care item as increasingly important, they are more and more likely to prefer that government spend more money on health care programs (Table 1). Indeed, on six of the seven items, their responses show a steady increase in support for more government spending as they rate a health care item as increasingly important. Hence, a greater proportion of citizens rating a program as “somewhat important” desire to spend more than those rating it as “not important.” An

11 even greater proportion of citizens rating the program as “important” desire to spend more than those rating it as “somewhat important,” and those rating a program as “very important” desire that even more be spent. The only exception to this pattern of intervalness is on the provider dimension pertaining to recruiting and retaining doctors, where Kendall’s tau b was statistically significant though Pearson’s r was not. One possible explanation is that state regulatory changes such as tort reform may be viewed as more relevant to the provider dimension than is merely increasing government spending. The absence of a comparable government spending item in the survey of legislators prevented a validity test of that dataset, but we have no reason to believe that our seven health care priority indicators, asked with identical wording of this more informed population, would behave any differently from the mass survey in terms of validity.

In comparing the health care attitudes of masses and elites, we rely primarily on means or averages of subgroup scores on the seven health care priorities (Nexon, 1971; Breaux, Shaffer, Cotter, 1998; Patrick, Shaffer, Cotter, Fisher, 2004). When conducting subgroup analyses by party identification, we rely on respondents’ self-reports of partisanship. The legislator survey contained a trichotomous party indicator, though only three lawmakers marked the Independent category. The public survey employed the seven point party identification scale used by countless mass voting behavior studies. We considered Independents leaning towards a party as partisans of the party they leaned towards, because of research indicating that such individuals behave in as partisan a manner in terms of vote direction as do weak partisans (Asher, 1992: 64-65).

12 There is considerable variation in the public’s and legislators’ responses on each of the health care items, justifying our use of four response categories for these items. While most of the variation pertains to responses to the categories of Important or Very Important, even the Not Important categories elicit some responses, particularly on universal health care. Furthermore, for substantive and theoretical reasons, we found it important to include the Not Important and Somewhat Important categories in the analysis. Not only do they ensure non-biased responses by providing balanced alternatives to respondents, but the generally modest number of responses in these categories illustrate how important the issue of health care is to Mississippians.

Mass and Elite Preferences on Health Care Priorities
It is quite evident that health care is an important issue to Mississippians, both to average citizens and to legislators. For each of the seven health care items for both masses and elites with one exception, the modal category eliciting the greatest number of responses is the Very Important grouping. Indeed, in ten of the fourteen cases, a majority of respondents chose the very important category (Table 2). The two most important priorities to both the masses and elites, with about two-thirds of both groups rating them as very important needs, are recruiting and retaining doctors to the state, and providing health care for children in low income families. Preventive health care and public education promoting nutrition and physical fitness are also important priorities, with over half of both masses and elites rating each as very important. Issues rated very important by a majority of only one of the two groups were improving the health status of minorities and providing health care for disadvantaged adults. The lowest health priority

13 was universal health care coverage, where a majority of neither group rated it as very important.

While both the public and lawmakers rated health care issues as important, it is nevertheless quite interesting that on every health item except one, state legislators rated health care as an even more important priority than did citizens (Table 3: columns 1 and 4). Somewhat surprising for a state where political observers two decades ago viewed public officials as being more conservative on education and race issues than average citizens, today’s Mississippi state legislature appears to actually be more progressive than citizens on the key issue of health care (Krane and Shaffer, 1992). The one exception to this pattern is also revealing—universal health care coverage, where the public is more supportive than lawmakers. Not only is this the most ideologically liberal and controversial of the seven health care programs, but it is also the most expensive.

It is also quite interesting to observe that even in the face of general assent to the importance of health care programs, there are obvious differences between the two parties. Indeed, in the general public as well as among legislators, on every health issue except one, Democrats rated health issues as more important than did Republicans (Table 3). Such partisan differences on one health care item and other public issues were also the case among Mississippi and Alabama party organization members a decade ago (Breaux, Shaffer, and Cotter, 1998). They reflect the extent to which the two major parties in the modern South have different issue emphases that are consistent with party differences nationally, issue differences that emerged outside the South during the New Deal era. (Ladd and Hadley, 1973: 21). It is also interesting to note that the one issue where

14 significant party differences do not emerge pertains to the provider dimension, as citizens and legislators of both parties are equally likely to rate the recruitment and retaining of doctors as a very important priority. The fact that even today a majority of Mississippi state legislators remains Democratic, despite Republican party gains among average citizens who today are more evenly split between the parties, may help account for the somewhat greater priority that legislators place on health care than do average citizens.

These intriguing partisan differences on the importance of health care are more fully examined in Table 4. The first two columns indicate not only whether partisan differences in health care priorities exist, but how great the differences are. The positive numbers reiterate that Democrats place a greater priority on every health care item than do Republicans, except for doctor recruitment where few party differences exist. Comparing across items, it is quite evident that the most controversial health issue that produces the sharpest divisions between the parties at both the mass and elite levels is universal health care. Providing health services to needy adults also elicits significant inter-party disagreements, while improving the health status of minorities and providing health services to needy children produce some party differences as well. It is also quite interesting that on all four of these issues, party differences are greater among the elites than they are among the masses. Such greater polarization between the parties at the elite level compared to the mass level is found nationally in the literature on a great range of issues. Its existence among legislators in the modern South on such a key issue as health care illustrates how the New Deal party system now extends nationally, as the South has rejected the Third Party politics of discontent reflected in the presidential candidacies of George Wallace and Strom Thurmond.

15 Given the very obvious partisan differences emerging on some important health care issues, it is important to ascertain whether one party’s leaders do a better job of representing the views of the party’s rank-and-file than do the other party’s elites. Scholars have speculated that Republicans lost presidential elections after 1932 because their own party leaders nationally were too conservative even for their own party’s followers, while Democrats may have faced a similar problem in the late 1960s and early 1970s. The issue of health care in modern Mississippi, however, produces far more complex patterns that depend on the specific health care program. On preventive health care programs, public education programs promoting nutrition and physical activity, recruiting doctors, and even improving the health of minority groups, elites of both parties place a greater priority on these programs than do the masses of their party (Table 4: columns 3-4). Perhaps legislators entrusted with the responsibility of caring for the health care needs of the public at the lowest cost possible have a greater understanding of the complexity of this issue, and view such health programs more as a way of saving public money in the long run than as an element of any ideological crusade.

The three other issues, which also elicited the sharpest polarization between the parties, exhibit at least a slight tendency for both parties’ elites to be more ideologically concerned than the parties’ masses. Regarding health care for needy children, needy adults, and universal health care, Democratic elites place a slightly higher priority on them than do Democratic masses, while Republican elites place a somewhat lower priority on them than Republican masses. These differences between party elites and masses are not great, however, except for Republicans on the issue of universal health care. Republican legislators place a much lower priority on providing universal health

16 care than do Republican party identifiers in the state population, reflecting party leaders’ historic opposition to “socialized medicine” which dates all the way back to their opposition to President Truman’s unsuccessful health initiatives.

When assessing whether the legislature as a whole is representative of the opinions of average citizens, and whether legislators of one or both political parties are out-of-touch with the views of the state population, it is also informative to divide health issues into two groups. On public education, preventive health care, improving the health of minorities, and recruiting doctors, all legislators combined place a higher priority on these health programs than do average Mississippians who identify as Independents, Democrats, or Republicans (Table 4: column 5). Interestingly enough, Republican lawmakers on all of these issues except recruiting doctors are somewhat closer to the views of average Mississippians than are Democrats (Table 4: columns 6-7). While Republicans view these health programs as important, as do average Mississippians, they are not quite as enthusiastic about them as Democratic lawmakers are. However, this is not a huge partisan divide, since the average Democratic lawmaker may rate three of these four health programs as “very important” and one as “important,” while the average Republican legislator may merely rate two programs as “very important” and two as “important.” Democratic lawmakers may have to beware of their enthusiasm for these health care programs leading to their party’s support for a possible tax increase or cuts in other popular programs such as education, which a public slightly less enthusiastic about health issues may resist. Again, one argument that Democratic lawmakers could make is that government backing for preventive health programs might cost tax dollars in the

17 short term, but save money in the longer term by reducing state Medicaid payments for treating some long-term illnesses.

The three issues that elicited the most divisions between the parties—health care for children, adults, and universal coverage---produce an interesting “polarized” perspective on the nature of representation. On each of these issues, Democratic lawmakers place a somewhat higher priority on them than do average Mississippians, while Republican legislators place a somewhat lower priority on them. Thus, while Democrats may run the risk of making these health care issues a higher priority than desired by voters, Republican run the opposite risk of relegating them to a lesser priority than the public desires. Perhaps an illustration of this is the recent cuts in Medicaid funding successfully proposed by Republican governor Haley Barbour. Not only have they produced a storm of public protest, particularly by the affected population and its advocacy groups, but the state’s Attorney General, a Democrat, has filed a lawsuit seeking an injunction to prevent the cuts from being enforced.

Interestingly enough, the rise of a competitive two party system in Mississippi may actually be promoting the representation of average citizens by their lawmakers. The more progressive views of Democratic legislators help counteract the more cautious views of conservative Republican lawmakers. Therefore, on the issues of health care for children, adults, and universal coverage, the views of the “average” lawmakers is very close to those of the average citizen, being separated by less than two-tenths of a point (Table 4: column 5). The other four health issues reflect a legislature slightly more progressive than average citizens, though the differences remain below a half-point, and

18 generally pertain to issues where lawmakers can argue that costs would be reduced in the long term. Each party’s lawmakers are consistently within six-tenths of a point of average Mississippians’ views on all issues except universal health coverage. On this one issue, Republican legislators are clearly more conservative than average Mississippians, and run the risk of being out-of-touch with the average voter (Table 4: column 7). It might appear counterintuitive that Democratic lawmakers would be closer to voters than Republican legislators are on such an expensive program, but perhaps the public appeal of universal health coverage is that it may be viewed as benefiting the middle class rather than merely the socially disadvantaged. If so, this suggests a policy strategy to Democratic lawmakers that rejects the conventional wisdom of seeking piecemeal reforms in favor of a more ambitious go-for-broke strategy. Such a strategy would nevertheless be risky, since this issue is overall a lesser priority than the other health issues to voters, and it does elicit the sharpest party divisions among lawmakers and voters.

The classic studies of congressional representation found that the views of constituents could be represented by lawmakers through the process of officials being drawn from the same constituency as the represented, and therefore sharing the same values as the general population (Miller and Stokes, 1963; Erikson, 1978). While studies at the national level generally found that leaders reflected a variety of the diverse views of the public and sought to enact them into public policy, few studies focused on state policymaking or on an in-depth study of specific public policies (Uslaner and Webb, 1983). Our study provides such an in-depth study of the complexity of one important and

19 timely public issue—health care. Furthermore, we focus on representation in the Deep South state of Mississippi, a state whose political system historically denied fundamental human rights to an entire race of citizens. Our general conclusion is that representation does exist in modern day Mississippi on this fundamental domestic issue. Furthermore, the rise of a competitive two party system may actually be promoting representation of the public, as each party reflects a somewhat different aspect of public opinion on this key issue. Democrats are enthusiastic backers of a more proactive health care system, while Republicans temper their support for this health care safety net with skepticism over the rising power and expense of government.

The conventional wisdom of national studies, that Republican party leaders and public officials were too conservative for the average citizen (McCloskey, Hoffman, and O’Hara,1960), has been challenged by revisionists who claimed that Democratic party activists nationally by the late 1960s had become the more evident ideological outliers, though in a more liberal direction from average voters (Kirkpatrick, 1975). Focusing on the last decade of southern party politics, a third school has combined these two perspectives to suggest that leaders of both parties may be somewhat unrepresentative of average citizens and even voters of their own party, as both parties’ leaders have moved toward opposite ideological poles (Maggiotto and Wekkin, 2000; Patrick, Shaffer, Cotter, and Fisher, 2004). Focusing on multiple indicators of health care programs, an approach eschewed by these general studies, we find some support for this third school, though with two qualifications. First, Democratic legislators are to the ideological left of voters and Republican lawmakers are to the right of citizens, but only on those particular aspects of health care that produce the most significant differences between partisans in both the

20 legislature and the general population. Second, while national-level studies have argued that if a party’s elites diverge in values from average voters, this can produce such electoral debacles as Goldwater’s in 1964 and McGovern’s in 1972, our state-level study points out that some divergence by both of the major parties’ elites from average citizens can actually promote representation of public views by canceling out extreme views and representing diverse sectors of the population.

Our final conclusion is a plea for more in-depth studies of representation that rely on multiple indicators of a critical public policy issue. Previous studies at the national and even southern regional levels have employed a more scattergun approach, examining a diverse range of public policy issues but with only one specific indicator of each issue. We have found that employing multiple indicators of one timely issue can expose the complexity of an issue and produce analytically interesting insights. For instance, people may view an issue from different perspectives, such as from the standpoint of the health care consumer or of the medical profession’s producers, as reflected in the failure of the doctor recruitment item to correlate highly with the other six health items (items that better reflected “consumer” orientation). Those six items may also be further divided into two groups based on whether they elicit some partisan differences in emphasis, or whether they produce a more bipartisan approach. Even the three items eliciting the most partisan conflict in our study were not homogeneous in nature, as universal health care coverage produced a unique result, with Republican lawmakers being not merely substantially more conservative than average voters, but even significantly more conservative than their own partisan supporters in the general population. Clearly, more comprehensive studies seeking to briefly touch on a diversity of issues run the risk of

21 drawing conclusions that may merely be the artifact of the one aspect of the issue that they ask about. Regrettably for scholarly researchers, most public policy issues are far too complex and multifaceted to be treated in such an undifferentiated manner.

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24 Table 1 Construct Validity Test of the Seven Health Care Priorities Items (means are for the health care/hospitals spending item) Health Care Item Public education to encourage good nutrition and physical activity Preventive health care Not Important 2.29 (6) 1.91 (9) 2.18 (35) --(0) Somewhat Important 2.50 (55) 2.45 (42) 2.45 (66) 2.02 (18) Important Very Important 2.77* (273) 2.75* (258) 2.85* (157) 2.80* (336)

2.60 (167) 2.67 (188) 2.72 (236) 2.49 (148)

Improving the health status of minority groups in MS. Providing healthcare services for children whose families cannot afford health insurance Providing health care services for adults who cannot afford healthcare insurance Universal health care coverage for Mississippians Recruiting and retaining doctors in Mississippi

1.71 (10)

2.37 (56)

2.65 (191)

2.82* (238)

2.06 (49) 2.52 (10)

2.58 (59) 2.49 (21)

2.74 (166) 2.70 (156)

2.86* (198) 2.69+ (310)

Note: Cell entries are the means of the Health Care and Hospitals state and local spending items, with sample sizes in parentheses. This well established indicator ranges from a low of 1 for spending less to a 3 for spending more. For example, in the second to last row, the 2.06 value in the first column indicates that among the 49 Mississippians who rated universal health care as Not Important, their average preference was that government should spend about the same as it currently was on health care and hospitals. The 2.86 value in the last column of that same row indicated that among the 198 Mississippians who rated universal health care as Very Important, their average preference was that government should spend more than it currently was on health care and hospitals. * Pearson correlation between health care spending and health care priority item was significant at .001 level. + Kendall’s tau-b was significant at .061 level.

25 Table 2 Mass and Elite Responses on Health Care Items Health Care Item Public education to encourage good nutrition and physical activity Not Important 1.2% 0% Somewhat Important 10.8% 4.0% Important Very Important 54.7% 63.2% N Sizes

33.2% 32.8%

(512) (89)

1.7% Preventive health care 0%

8.2% 0%

37.8% 17.7%

52.3% 82.3%

(508) (89)

Improving the health status of minority groups in MS. Providing healthcare services for children whose families cannot afford health insurance Providing health care services for adults who cannot afford healthcare insurance

7.2% 0%

13.4% 7.1%

47.7% 38.2%

31.7% 54.7%

(505) (88)

0.1% 0%

3.5% 3.0%

29.2% 27.8%

67.1% 69.2%

(513) (89)

2.0% 1.0%

11.3% 8.0%

38.4% 39.8%

48.3% 51.2%

(505) (89)

Universal health care coverage for Mississippians

10.7% 18.3%

12.5% 13.2%

35.1% 30.1%

41.8% 38.5%

(482) (88)

Recruiting and retaining doctors in Mississippi

2.0% 0%

4.2% 4.7%

31.2% 12.7%

62.7% 82.6%

(507) (89)

Note: In each cell, the top number is the percentage of the public making the response listed at the top, and the bottom number is the percentage of the legislators offering the same response. These percentages may fail to total 100% across each row, due to rounding. The last column indicates the number of citizens and legislators who offered opinions on each health care item.

26 Table 3 Mass and Elite Responses, by Party, on Health Care Items (means) Health Care Item Entire Public Democratic Public Republican Public All Legislators Democratic Legislators 2.66 Republican LegisLators 2.50

Public education to encourage good nutrition and physical activity Preventive health care Improving the health status of minority groups in MS. Providing healthcare services for children whose families cannot afford health insurance Providing health care services for adults who cannot afford healthcare insurance Universal health care coverage for Mississippians Recruiting and retaining doctors in Mississippi Average N Sizes















































Note: Cell entries are means or averages of each of the subgroups listed at the top of the column, reflecting their response to the health care item listed to the left. Responses to the health care priorities range from 0 for Not Important to 3 for Very Important. The last row provides the average N sizes for each subgroup, averaged across the seven items.

27 Table 4 Differences in Health Care Views between Mississippi Groups (mean differences) Health Care Item Polarization Dem Elite – Rep Elite Public education to encourage good nutrition and physical activity Preventive health care Dem Mass – Rep Mass Proximity to Partisan Public Dem Rep Elite Elite Dem Rep Mass Mass Proximity to Average Citizen All Elites All Mass Dem Elite All Mass Rep Elite All Mass















Improving the health status of .38 .24 .48 .34 .44 .60 .22 minority groups in MS. Providing healthcare services for .42 .27 .07 -.08 .03 .21 -.21 children whose families cannot afford health insurance Providing health care services for adults who .68 .34 .20 -.14 .08 .35 -.33 cannot afford healthcare insurance Universal health care coverage 1.33 .63 .06 -.64 -.19 .33 -1.0 for Mississippians Recruiting and retaining -.10 .03 .17 .30 .23 .19 .29 doctors in Mississippi Note: Cell entries are differences between the group means, obtained from Table 3.

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