Rural America has moved toward strong Republican voting even though Republican governance helps explain worse health outcomes in rural areas, from hospital closures to opioid policies. Michael Shepherd finds that rural areas disproportionately suffer from Republican policies but Republicans successfully blame Democrats for worse health outcomes, especially when Democratic policies can be framed as helping immigrants or racial minorities. There’s no obvious way out for Democrats, who own health policy and its outcomes.
Guests: Michael Shepherd, University of Michigan
Study: Rural Pain, Republican Gain
Transcript
Matt Grossmann: Why rural areas vote Republican despite worse health outcomes? This week on the Science of Politics. For the Niskanen Center, I’m Matt Grossman. Rural America has moved towards strong Republican voting, and yet Republican governance helps to explain worse health outcomes in rural areas, from hospital closures to opioid and gun policies. Are rural Americans voting for the party that makes their health worse? And why? This week, I talked to Michael Shepherd of the University of Michigan about his forthcoming Chicago book, Rural Pain, Republican Gain. He finds that rural areas disproportionately suffer from Republican policies and have worse health outcomes as a result.
But Republicans successfully blame Democrats for these outcomes benefiting electorally, especially when Democratic policies can be framed as helping immigrants or racial minorities. There’s no obvious way out for Democrats who own health policy and its outcomes. This is an important conversation for Democratic accountability with real outcomes at stake. So, tell us about the findings and takeaways from your forthcoming book, Rural Pain, Republican Gain. What did you find?
Michael Shepherd: Yeah, thank you for having me. This book comes from my dissertation research and has been almost a decade in the making. Broadly, there are two sort of sets of things going on in the book. One is to diagnose the political and policy origins of rural health disparities. And the other is to understand the downstream mass behavior consequences of these health changes. And so, in part one of the book, I focus on healthcare policymaking at the federal and state levels. Part two of the book is focusing on healthcare, how healthcare experiences relate to rural partisanship and rural health policy attitudes.
And then part three of the book turns to three case studies that I think do a decent job of focusing on various aspects of the broader puzzle. What I find is that rural healthcare disparities in the US have political and policy origins and pretty severe consequences for rural health disparities from politics in general. So, rural people are substantially more likely to be benefiting from programs like Medicaid and from SNAP. And those programs at the federal level have been ushered into law by Democrats. Whereas policies that have been harmful for rural health overall at the state and federal level have been much more likely to come from the Republican Party.
And so, I try to trace qualitatively and quantitatively some of those policy histories as well as their rural effects. And so, that’s the first part of the book. But I argue in the latter half of the book that these outcomes in general, regardless of whether they’re coming from Republican or Democratic policymaking or things that we may view as more organic, contribute to what I call the rural health spiral. And that health spiral is essentially that bad outcomes become evidence for rural people that the government vaguely is failing them.
And that government isn’t functioning in a way that promotes better lifestyles, healthier outcomes, better economic outcomes in rural communities and creates quite a lot of resentment towards the government and cities that rural folks perceive as better off than them. The downstream effect of these attitudes is that it increases support for anti-government politics and anti-government politicians. In the US, that means the Republican Party, but that also hampers support for a variety of government health remedies for rural health woes.
And when that spiral kicks off, where bad outcomes lead to the rejection of government and the election of politicians who further reject government, we sort of see a spiral of worse outcomes being occurring later down the spiral. And those outcomes, again, creating this self-reinforcing feedback loop where bad outcomes lead to anti-government politics and anti-government politics lead to bad outcomes.
And the resulting partisanship and effects on partisanship that occur from this, as well as appeals by more conservative politicians to the shared rural grievances and resentments, the more the Republican Party is insulated from accountability for their own policymaking, the more Democratic politicians are blamed for bad outcomes of a variety of sorts and a variety of causes.
Matt Grossmann: So, this is of course an academic publication, but it also draws from your personal experience. So, tell us a little bit about the story behind the book and kind of your background and first reactions to academic studies of rural Americans and how you adjust it.
Michael Shepherd: Yeah, that’s a great question. So, I grew up in rural Kentucky and so a lot of the interest in this research area comes from those experiences. Most of us that study rural politics, at least in the US context, I would guess if you surveyed us, the vast majority of us have some story like this where we grew up in rural areas. That’s what got me on the topic. I think some of my first political memories were watching my community shift from a town that was overwhelmingly democratic in the 1990s to a town that very quickly became majority Republican and was always curious as to why that was occurring and what forces were contributing to it, not only in communities, not only in my community, but communities like it.
And that certainly is sort of how I ended up here. Like a lot of us, the rise of Donald Trump in 2016, I think opened up a lot of potentially new avenues of political science research. And that just happened to be when I was in grad school writing a dissertation and decided that what I really wanted to get at was why it seemed like people from communities like mine were so supportive of candidates like Donald Trump and of the Republican Party more broadly. And what that meant for people’s health. At the time, things like the opioid epidemic were ravaging communities in Kentucky.
And I was deeply alarmed by those experiences and wanted to study them, but I also was increasingly seeing some connection between experiences like that and people’s politics and a resentment that had been building from this community level problem that had been somewhat ignored by policymakers and was all of a sudden thrust onto the political scene in 2016. And so, I would say those were formative experiences for me. And the timing was really, I think, similar to how a lot of us felt that at least people who had rural experiences, which is like, there’s some things out here that are missing and some things that could be done better.
And for me that academically, it was Kathy Cramer’s book that really, I thought, started to stitch together some of the key things that had been missing. And I was fortunate enough to have Kathy’s mentorship and advice on my dissertation, but also on this book. And that really, I think her insights gave me, and many of us, a framework for trying to understand how we can conceptualize and operationalize the attitudes and experiences of rural people.
Matt Grossmann: So, how much of the gap in health outcomes and experiences between rural places and elsewhere is actually about public policy? Is it about state or national policy and how much can we really nail down this partisan interpretation of those policy differences?
Michael Shepherd: Yeah, it’s a great question. Some of this is about demographics. People in rural places are older, people in rural places often have lower incomes, lower levels of educational attainment, and engage in a variety of activities, hobbies, et cetera, that we might consider as riskier or less good for their health, things like firearm usage and stuff like that. So, there’s no question that I think demographics are going to be really critical for shaping the nature of rural disparities in general, but there are unique policy causes driving the depths of rural health woes in the US relative to other countries, other peer countries.
So, if we look at wealthy Western democracies, the differences between urban and rural health outcomes in the US are substantially larger than we observe in the rest of the Western wealthy democratic world. While some countries, for example, Canada have small differences between rural and urban, some have rural health advantages or there’s parity between rural and urban. We don’t really observe large rural urban differences or as large of rural urban differences as we do in the United States, really in any peer country. Where we observe similar levels of differences are countries that are either not democracies or they’re not as economically developed as the US.
So, countries in Latin America, countries in Africa, countries in Asia that are not democratic or have lower levels of economic development are where we see the most similar urban, rural gaps, albeit rural health in the US is still going to be somewhat better than some of these peer countries. It’s just that size of that gap. And I think a lot of that has to do, and what I say in the book, a lot of that has to do with the nature of our social safety net and the nature of our more privatized or relatively more privatized healthcare system. Healthcare in the US, unlike any other peer country is a profit driven enterprise and rural areas are not particularly profitable for a private sector healthcare industry.
The same demographics that I’ve laid out before, older populations, more sparse populations, lower income, less likely to have health insurance, those don’t make for particularly profitable coverage areas for the healthcare sector. And as our policymaking environment, especially over the last 20 years, but even a bit before, has injected more private sector influence into the healthcare setting, things like private equity, et cetera, those have really been harmful for rural areas, especially in communities and states in which there are other policies which I get into in the state policy chapter that make matters worse.
So, I see at the federal level, the social safety net or the lack thereof in its universalism, as well as things like the increased role of the private sector and the delivery of healthcare has been uniquely harmful for rural areas in the US. At the state level, things are clearer. It’s not that I would necessarily say that state governments are more or less important, it’s just that we have better data and more spatial and over time variation at that state level to capture some of these differences. And most of these differences have emerged since the 1990s.
So, if we were to look at data from the middle of the 20th century, we really wouldn’t observe large differences between Republican states and Democratic states. If anything, what we would see is that more competition between the two parties led to better outcomes, but really since the 1990s, there’s been a critical divergence on things related to Medicaid generosity, to firearm policies, and a variety of other policies that have health related effects. And I think firearms policy is a particularly useful one to look at. In the 1970s, 1980s, there really weren’t large partisan differences in state firearm policies, but since the turn of the century, we’ve seen massive, massive differences.
Most Republican states are going to have things like open carry laws or stand your ground laws, whereas very few Democratic states have them, and there are pretty severe downstream consequences from those decisions. If we look at firearm fatalities over the last 20 or 30 years, what we observe is that most of the increase in firearm fatalities in the US is driven by Republican states and Democratic states have had mostly flat lines. And if we look within those states, it’s rural areas where we’re seeing the largest increases in things like firearms related suicides.
That’s not just my work, although I do try to contribute to this literature in this space, but work by Jennifer Karas Montez, Javier Rodriguez, and others have shown using a variety of outcome variables that what we’ve observed over the last 30 years, especially is a pretty sizable divergence in healthcare policies and outcomes at the state level, largely by the partisanship of the states.
Matt Grossmann: So, some of…
Michael Shepherd: … By the partisanship of the states.
Matt Grossmann: So some of what you have been talking about seems pretty specific to healthcare, that is the economics of a private healthcare provision in rural areas, but others seems like maybe a broader story about policy differences in states and kind of failures of accountability for those differences. So how much do you see this as kind of a general story and explanation for geographic polarization? And how much is it a repeated story that we would find in lots of different policy areas versus one that’s specific to the economics and politics of healthcare?
Michael Shepherd: That’s a great question. I try to discuss this in detail in the conclusion of the book because I do want to provide appropriate scope conditions on what I’m talking about. The empirical analyses, the focus of the book is all drawing on health policy. And health policy is unique in a variety of different ways. Some ways that I think the findings might be limited in certain respects would be especially regarding people, the policy attitudes. There are some policy areas that are easier for elites, politicians, the media, et cetera, to manipulate and move. And there are some areas that are harder. We’ve known that for a long time from Carmines and StemCen and others. Healthcare and health policy in particular is very complex. It’s very difficult to understand. And as a result, people are often looking for cues, information, shortcuts, frames to try to understand what’s happening and why it’s happening.
And so I think in the most direct limitation here is that when I show things like the influence of partisanship or cues related to party or frames related to race and place, having such a large influence on people’s policy attitudes, we might think that those things might be limited to policy areas that are more complex and harder for people to understand and less so and easier to understand issues where people may be able to map their underlying values or preconceptions of those policy areas onto the outcome. So I think that’s an important one, but I try to do some walking through with like, what are the other areas where we maybe would think this would be applicable. I think environmental politics is an area where we see some evidence of this.
Environmental policy can be fairly complex and difficult for folks to understand. It’s also the case that there’s a place-based component to this where rural industries and rural areas, things like coal mining, agriculture, are harmful for the environment, but policymaking in that space may regulate industries in ways that are not favorable for people’s economic outcomes or for their jobs. And might be areas where we could see similar dynamics of policies that are hurting the environment, especially because of this job trade off, where we observe sort of the same kind of backlash effects or resentment stemming towards those policies.
The way I talk about this in the book is through an issue ownership framework. A lot of what I am arguing is that Democrats catch a lot of the blame for health policy related things because the most salient health policy in the last 20 years has been the Affordable Care Act or Obamacare, and that policy is connected to the Democratic Party and Democrats in general have owned the issue of healthcare for a long time. And so we might think of these dynamics as sort of issue/ownership is often viewed as like a source of political strength for parties, but it could also be a source of political weakness if we think that failed or bad outcomes in that space can contribute to a party catching blame for particular outcomes. So things, again, in that area, we might say maybe education related, policy issues, environmental policy issues.
Maybe those are areas where we see the dynamics sort of functioning the exact same as we observed in healthcare policy and perhaps things work differently in other issues like immigration. If immigration failures might be a source of liability for one party over the other in a different way. But I try to sort of walk the reader through things related to the post ACA timing of things, issue domain specific factors, and try to be cautious about, we maybe don’t want to generalize beyond health policy, but there are some reasons that we might think we can’t. So it’s drawing on work from Jake Grumbach and others. We can see that many of these Republican states have lower median incomes, higher levels of unemployment, fewer labor protections, and those things we might think would lead voters to rally to the Democrats if they’re frustrated by them, but there’s not a lot of evidence that that’s occurring either.
And a working paper that I have, I show that there’s really not much evidence that things like poor economic outcomes under Trump’s first term for rural places or better ones under Biden did much to move people’s voting at all. And that may suggest that this is sort of an era of politics in which policy related factors are somewhat decoupling to varying degrees from how people assess politics. But I certainly would say that there’s at least some evidence that what I’m finding is generalizable beyond health policy, but perhaps not to all issues.
Matt Grossmann: But you do forward this bait and rebrand alternative to the traditional kind of bait and switch explanation for the rise of Republican politics, which is a lot more concerned with the national rise of social and cultural issues relative to economic issues. So I guess give us the case for why this isn’t just about social conservatism or the general kind of culturally liberal national trends of the Democratic Party.
Michael Shepherd: Yeah. So I draw on this from Thomas Frank’s, What’s the Matter with Kansas. He refers to this as a bait and switch with the bait and switch being Republican politicians campaigning on culture war issues like abortion and then instead cutting social security. And in his framework, the voters are duped. Basically, they’re promised one thing and they’re given another. That’s not exactly what I see. I don’t observe Republican politicians focusing on culture war identity issues and then sneaking in plutocracy or conservative economic policies. Instead, what I see is that these politicians have successfully rebranded various aspects of the social safety net policies that are helpful for lower income people and working class people as part of the broader culture wars. They’ve successfully rebranded a policy like Medicaid as something that’s part of the culture wars as opposed to distracting them with culture war issues and then doing something to Medicaid behind their back.
What I really observe is that they’re successful at making programs like Medicaid, like SNAP, be understood in culture war identity-based terms, us versus them, rural versus urban, Black versus white. And that is, I think key here is it’s not that people are inherently, that Republican politicians are inherently promising one thing and doing another, it’s that they’re fusing those two things and expanding the range of cultural considerations, identity-based considerations to things like social welfare policy.
Matt Grossmann: So let’s talk through a couple of the cases. What did you learn specifically about opioids and about hospital closures and why was it that Democrats were blamed for failures in these areas? And were there any cases where Republicans were blamed?
Michael Shepherd: Yeah. So in the case of the opioid epidemic, what I mostly observe is a reaction to Trump’s campaign rhetoric more than any specific blaming of Democrats inherently for their policies. The opioid epidemic really started affecting rural communities, especially ones in Appalachia in the late 1990s and early 2000s, and festered in these communities for over a decade without really any political attention or any media attention. So if you look at things like how many times was the opioid epidemic mentioned in the New York Times from 2000 forward, you see there was basically no media coverage of this really important issue up until 2015 and 2016. In 2015 and 2016, two things happened at the same time. One was that the synthetic opioid epidemic, things like fentanyl, really came to start rocking major urban areas. And Donald Trump’s campaign, as well as the national media, both the traditional media as well as through books like Dreamland, elevated the salience of the opioid epidemic in ways that we had never really seen before.
And so for a lot of people that have been living in these communities experiencing bad opioid outcomes for a long period of time, this became the moment, and to draw on Dan Hopkins’ great work, Politicized Places, that these opioid centers became newly political, and those experiences became newly political in 2016. What we see in aggregate, like county level data from scholars like Shannon Monnat and others, is communities that have been negatively affected by the opioid epidemic, their voting behaviors had stayed largely the same from 2008 through 2012, but then in 2016, there was this major shift towards Donald Trump. In the book, I talk about Portsmouth, Ohio as sort of a classic example here. Portsmouth was one of the early hotbeds of the opioid epidemic. In the book Dreamland, Portsmouth is pitched as one of the first, if not the first opioid pill mills in the country.
Overdoses had been climbing for well over a decade, but the politics of Portsmouth really didn’t change until 2016 when there was a massive shift towards Trump. In the book, I draw on survey data to show that how this happened at the individual level was not only that people who knew someone who was addicted to opioids shifting, but they did so largely at the same time with sort of coming to understand the opioid epidemic as an immigration problem, as well as a rural urban problem. So Trump’s rhetoric fused the opioid epidemic with things like immigration, things like crime in American cities. And what we observe is that not only did people who knew someone that was addicted to things like painkillers shift their political support in 2016, they also adopted more anti-immigrant attitudes and became more hostile towards racial and ethnic minority group members.
And so I sort of view this as Trump rallying to an ignored health issue that many rural folks were resentful about and fusing this with a broader culture war question related to racialized politics as well as immigration politics and racialized immigration politics to rally support from folks who had been negatively affected by the opioid epidemic.
In terms of hospital closures, there I think we see a clearer story for policy failure and a role for politics that I think really drives home a lot of the key dynamics of the book. Rural hospitals have been closing for decades and increasingly over the years, but Medicaid expansion under the Affordable Care Act offered a financial lifeline to a lot of these hospitals, primarily occurring through reductions in the amount of people who were showing up to receive medical care at hospitals without health insurance, call this uncompensated care. The Medicaid expansion or the Affordable Care Act drastically reduced uncompensated care loads for rural hospitals especially.
And so what we observe is that rural hospital closures continue to increase over the post-Medicaid expansion decision period for those states that did not expand Medicaid. And for states that did expand Medicaid, we saw hospital closures drop down to one or none a year, basically.
And what I did to explore the political effects of this was to look at cases in which a rural community lost its sole rural hospital in a state, a Republican state that did not expand Medicaid and compare the attitudes and voting behaviors of people who lived in the community that lost their hospital to peer communities, peer other rural communities that did not lose their hospital in the same time period that were similar demographically, politically, et cetera. And even though it was Republican decisions to not expand Medicaid that increased closure likelihood or made it to where the hospitals did not receive this financial lifeline that the Affordable Care Act was offering, we observed that rural voters were much more likely to penalize the federal Democratic Party, Democrats in general, and they blamed the ACA for these effects. And state Republican politicians, the people who were more responsible for the lack of Medicaid expansion, if anything, gained from this decision. The salience of the ACA and the timing of these closures fused, in my mind, these healthcare experiences with the Democratic Party and made it easier for local Republicans, both politicians as well as members of the public to point to the ACA in general as the cause of this hardship, as opposed to the lack of Medicaid expansion being the driving factor behind these closures.
For the Tennova Regional Healthcare Center in Selmer, Tennessee, I did an in depth case study where I looked at, how was this discussed on social media? How did people find out about the hospital closing? And was there evidence that what I was seeing in the survey data, was that backed up on the ground?
And so I found the original post from this online news source that the hospital in Selmer, Tennessee, a rural county outside of Memphis was closing. And you didn’t have to go more than one or two comments in to see several people in a row blaming the Affordable Care Act and Obamacare for the closure, even though in reality, it was the state’s lack of Medicaid expansion that contributed to the closure. And to this day, Tennessee ranks near the top in terms of states with a number of rural hospital closures. And so what you see is this sort of bad outcome leading to resentment towards the government, resentment towards Democrats, resentment toward the ACA and Republican politicians gaining from those bad outcomes, even though those bad outcomes were made more likely as a result of Republican policymaking.
Matt Grossmann: You also find that partisanship explains a lot of the rural health policy opinions in general, but that you see big differences in levels of support for health policy when the beneficiaries are mentioned, immigrants or racial minorities. And you also find that politicians can successfully kind of activate racial resentment to oppose these kinds of policies. So how racial of a story is this? On the one hand, it doesn’t seem as racial as some of the characterizations of a rural change in the US. On the other hand, you can kind of show that these rhetorical attributions make these big changes.
Michael Shepherd: Yeah. So I wouldn’t say this is inherently a very difficult question to answer because race and party are fused in many respects in the real world. And so separating their independent effects is quite difficult. Andrea Engelhardt has a variety of really great work on this question. So my starting place for this is two things. The Dying of Whiteness book by Jonathan Metzl and Michael Tesler’s fantastic work on the racialization of healthcare policy. And in Metzl’s telling, there’s sort of a naturally, or as I say in the book, organic racism that explains people’s healthcare policy support and politics, that rural people are sort of just reacting to things like the ACA and not supporting it or not engaging with it due to their underlying racial attitudes. I think the story is a little bit more nuanced that and is a little bit more similar to Michael Tesler’s argument, which is that healthcare isn’t something that is naturally just racialized to the same degree as maybe some other policy areas and is instead someplace where we really think that elites political messages must contextualize that policy and racialize that policy, to use his terminology.
So the way I look at this in the book is with two survey experiments, both are fictitional health policies, things that are not being debated actively in the real world, things where we don’t think people have strong underlying attitudes one way or another. In the experiment, I described the policy. They’re always involving pretty sizable increases in government involvement and paying for people’s healthcare. Policies that we would say are pretty liberal, maybe too liberal for virtually any state to enact. And after describing this information, the control group, that’s essentially all they’re told. Right. In the first experiment, the control group is just given the details of this very liberal policy. The idea behind doing this is basically to see if people are hearing a health policy and immediately evaluating that policy on the basis of their underlying partisanship, or racial attitudes, or their underlying conservatism, we would see pretty low levels of support in the control group without any new information.
But if instead, as Tesler argues, as I argue here, that what is actually happening is that elites are racializing the issue, they’re directly connecting racial considerations to the policy, then we would only observe that decrease if following an elite policy frame connecting the policy to the politics of race and ethnicity, the politics of immigration. And what we observe is that simply by mentioning that a policy in addition to benefiting rural people would also go to benefit members of racial and ethnic minority groups or go to benefit immigrants, that rural people are substantially less supportive of the policy than the control group. In the control group, however, they’re very favorable towards the policy, and that suggests it’s not some underlying organic consideration or underlying set of predispositions towards the policy. It’s this elite framing, the elite policy discussions that are really shaping people’s policy attitudes towards health outcomes.
And what we observe are that these racialized policy frames, if anything, have stronger effects on those with the most to gain from the policies, people who have chronic health problems, people in medical debt, we see that these frames have just as strong, if not a stronger effect on those respondents as they do the average rural respondent. I look at that as suggesting people aren’t intuitively applying their racial attitudes to health policy. It is instead elite communication that is fusing the two, and you can shift rural voters from being majority supportive of a variety of different liberal health policies to being majority unsupportive on the basis of racialized policy frames.
The way I get at partisanship in this dynamic is in a second experiment where I essentially… A new fictitional policy, but this time the treatment is essentially varying whether or not Democrats, Republicans, or experts are saying that the policy will help people who live in cities, immigrants, versus helping rural people just like them. And what I find is that people who are receiving in party messages are much more supportive of the policy than people who are receiving out party messages, whereas the experts messages in general are serving as the control group in this case, but that racialized information and even place-based information has a much, much larger effect if out party members are saying, “This is going to help people who live in cities. This is going to help immigrants than if in party members do.”
That suggests even further that the influence of these racialized policy frames is in and of itself affected by partisanship, that instead it’s sort of not just that the racialized policy frames are driving attitudes on their own, they must be queued by elites, but that it’s particular elites that are able to have the most influence on policy attitudes. So for a rural person, hearing from a Democratic politician that a policy is going to help a city or help racial and ethnic minority groups or help immigrants is the thing that induces the most backlash from rural respondents. But if a Republican says the same thing, there’s actually less evidence that it moves attitudes very much and the use of experiments, survey experiments allow us to tease out a little bit closer the individual or independent effects of things like race, place, and party in ways that are quite difficult to do with observational data.
Matt Grossmann: So one place that residents may hear a lot about these frames is from conservative media. And you find that especially in areas where there’s a little local news anymore, that people are reliant on conservative media, and this plays an important role in the COVID case that we haven’t talked a whole lot about. So talk us through what you find in the COVID case and the role of media.
Michael Shepherd: Yeah, absolutely. So I look at the information environment and media, not inherently as a independent or main driver of these attitudes or the partisan effects, but as instead a key mechanism for how these cultural frames, these racialized frames and partisan frames are circulated in rural communities, how they come to affect people’s broader politics. What we see is that the vast majority of rural areas are in local news deserts and that they have zero or just one newspaper. Time and time again, when I would look to try to see how did local media cover various aspects, various health things that I was discussing in the book, what I would find is no newspaper or at best, the sort of social media based, Facebook based Gazette style newspapers where it’s a local person that started their own page. Some of it functions as a gossip page, but some of it is just their take on all things politics as well as local things.
And that in many cases is like the best case scenario. Many rural people are in situations where their local television news, for example, is coming from a large city very far away, and those media outlets don’t really take very seriously what’s going on in small areas. So with co-authored work with Josh Clinton and NG Kim during the pandemic, we found that people who were getting their television news media from big cities like New York City were responding to the COVID pandemic in ways that were more consistent with the conditions in New York City than in the conditions in their own communities, relative to rural people who were getting their local news from smaller city markets. So if you’re getting it in New York City versus Binghamton, New York, for example, even when we think about the differences perhaps in local COVID exposure. But those outlets are, again, covering what’s going on in those cities.
In the case of COVID, that actually meant something good for public health, which is that people were seeing the public health threat of COVID-19 and elevating their concern and were more likely to do things like stay at home and not travel, but in places that were being presented a more tranquil environment or less of a COVID threat, people were mostly going on like nothing was happening. And what I observe a lot in the COVID chapter is through spring and summer of 2020, most rural places were not heavily hit by the COVID-19 pandemic. Things were functioning essentially as normal in a lot of those places, but that attitude that had been in some ways shaped by things like social media, local political elites, or even this dynamic with local television news later contributed to a real problem when in the fall of 2020, the COVID-19 came in full burst into rural areas. And what we observe is basically people who had already locked in their attitudes about COVID-19, the partisan media related and discussions of COVID-19 had already come to shape how people felt about it. When things hit and things actually got worse in rural areas, when we would hope people were alarmed and engaging in precautionary behaviors, we saw that people’s attitudes were already where they were going to be. Concern didn’t really increase very much. People were not engaging in precautionary measures. That had real effects on death rates in rural areas, especially once the vaccine became available and rural attitudes towards the vaccine had already become quite unsupportive and untrustworthy.
What I see, the broader media role here in my view is that rural people aren’t finding out things about their own communities in an accurate way from the local ABC affiliate. They’re hearing about what distant cities are experiencing. I recently read a paper, I believe, from a WashU graduate student that showed similar dynamics are occurring in the area of crime policy where rural people who get their news from big cities that have higher crime rates are more likely to have punitive, more conservative attitudes towards crime than people who are getting it from places that are more tranquil perhaps in terms of their crime coverage, and then that can have downstream effects. I think media is important, but I think mostly what’s happening, whether or not it’s shaping attitudes in a conservative or liberal direction really depends on what policy domain we’re talking about when it comes to local media.
But the broader phenomenon is that in lieu of being able to find out about why my hospital closed on local media, what people are instead being exposed to is national political news on things like Facebook as well as talk radio, and that Nick Jacobs and Dan Shea refer to this group of people as rural rabble rousers, which is the very political, very conservative members of rural communities who are sharing Fox News stories, right-wing blog outlets and a lot of right-wing information across the social media pages in rural communities that are reinforcing these frames. When people talk politics at all or learn about local politics at all, it’s not coming, by and large, from some journalist who knows the ins and outs of why a thing happened and is instead some confluence of local conservative voices, local Republican politicians, word of mouth from neighbors, and very rarely detailed reporting.
Matt Grossmann: You don’t shy away from one of a listener’s favorite topics of what should the Democrats do all about this? But I don’t know how well the solutions can work. On the one hand, you show that various attempts to deliver actual policy gains for rural areas haven’t helped. The effort to prioritize healthcare has ended up potentially backfiring for Democrats in some respects. In the latest debate, there was a lot of talk about rural health policy and hospital closures around the One Big Beautiful Bill. It did result in a policy change at the last minute with a new fund, but a lot of this… You downplay the potential of Democrats to be able to use moderation on cultural issues to win back these voters. It sounds like a lot of this is in motion and hard to reverse, but how much is it under Democrats control? On the easy side, might just be actual organizing and campaigning more in rural areas, but what’s our confidence that that would materialize in changes in votes?
Michael Shepherd: Yeah. That’s a great question. I think in general, I come down on the view that the high-level messaging decisions are… Especially regarding moderating on culture war politics is just… There’s not a ton of evidence that that is going to work and not a ton of evidence that it’s super consistent with how public opinion fluctuates. Things like immigration attitudes have already shifted quite substantially under Trump 2.0 in ways that would suggest moderating might not make a lot of sense for where the public is now relative to where they were before. But it’s also the case that I show in many respects that just doing good policy isn’t really enough anymore and doesn’t play particularly large political dividends at this point for a variety of different reasons. That doesn’t mean that those policies aren’t worth doing. It doesn’t mean that trying to improve outcomes in rural communities aren’t worth doing.
It just means that the work in many respects is just starting at that point. I think one of the big reasons, and there’s been some work recently published that suggests this was part of the problem, was that it wasn’t necessarily that the Biden administration failed to deliver good policy or good policy outcomes for rural people. It was that they failed to organize around those policies and communicate around those policy successes in local communities. With Parrish Bergquist, we’ve been doing interviews in a variety of different communities that received investments from the IRA. Most people really just didn’t know why a factory was being built in their community and what politics had to do with it. Work that was recently published in PNAS suggests if anything, they thought governors were responsible for these things and not the Biden administration. It suggests to me that there’s really not a lot of on-the-ground organizing and communication occurring in a lot of these rural communities to connect policy realities to broader electoral politics.
This is the case when you look at party organizing specifically. In co-authored work with Clinton Willbanks, we found that there are many rural communities across the country where there’s essentially no Democratic Party apparatus. They’re essentially not campaigning. They’re not competing for local offices. They’re not running. The Democratic Party’s very much from 2016 forward adopted somewhat of an efficiency model of campaigning, locating campaign resources primarily in highly populated more urban areas that have more Democrats and have largely withdrawn from a lot of rural parts of the community. I think more subtly, there are lots of rural people that run in these spaces that would tell you that if they do get assistance from the Democratic Party or organizational help from the Democratic Party, it’s often not attuned to local needs or local voices or local concerns, and instead is the consultant class parachuting into a small town and trying to tell someone who’s lived there for 30 or 40 years, that they need to adopt some particular campaign strategy that maybe doesn’t meet the realities of rural life.
The knocking doors doesn’t work the same way in a rural area as it does in an urban area, even though that’s a part of the primary GOTV toolkit. I think Democrats first have to decide whether or not they see value in organizing in rural areas. One’s answer to that question I think will vary from person to person, but if they do, I think this needs to be viewed as a long-term project and not a one-term, one-off presidential election problem. Dan Galvin in particular works really registers with me on this, which is that the Democratic Party has largely been a series of presidential campaigns and presidential administrations without much party building. The Republican Party is a series, now at least, of social movements, but over the 20th and 21st centuries of party organizing from the bottom up.
Democrats really haven’t done a lot of that. When you go into rural communities, it’s pretty easy to find local Republicans, local Republican Party organizations. When you go into social settings in rural areas, the Republican Party is present and is ingrained in rural life in a way that the Democratic Party really isn’t. The Democratic Party for most rural people is a group that shows up at election time rather than a group that’s really invested in their communities. If you really want to build back support in rural communities, it has to be part of a longer term organizational project as opposed to… That wins back over trust, that finds local voices, that elevates local people, and puts a rural face in these areas on the Democratic Party.
That’s just a pretty big ask, I think, for a political party that sees little electoral gain from their policymaking and has other groups of voters that can be reliably counted on for support. Whether or not that organizational effort is worth it is I think somewhat of a question for Democrats to answer for part of their broader strategy. They may not view it worth the time or effort to do such a thing, but I will note that that decision, if anything, just reinforces the viewpoint that many rural people hold that Democrats don’t care about them or communities like them, or they don’t see it as worth the effort. That will, if anything, just contribute to this dynamic playing out further for years to come, and is probably worth on its own reckoning with.
Matt Grossmann: Anything you want to tout about what is next for you or take home messages you want to leave us with?
Michael Shepherd: Yeah. Well, again, I just wanted to thank you for the time. This has been a lot of fun. I hope people will read the book, dialogue with it, enjoy it. What’s next for me? Finally, getting back to a series of projects that had to be somewhat paused while I finished things with the book. I mentioned with Parrish Bergquist, we’re working on a variety of projects related to the IRA and its failure to deliver political wins for the Democratic Party with Alee Lockman and Krissy Lunz Trujillo working on a variety of projects related to socialization in rural communities, how much of what we observe regarding not only things like rural health outcomes or rural politics are a function of growing up in a rural area. All three of us grew up in rural areas, and so once again I think returning to the source of inspiration being our childhoods and our livelihood for what we’re studying and continuing I think to work in a space of trying to address some of these rural health woes in a variety of policy-centric ways is very much top of mind for me.
Matt Grossmann: There’s a lot more to learn. The Science of Politics is available biweekly from the Niskanen Center, and I’m your host, Matt Grossman. If you liked this discussion, here are the episodes you should check out next, all linked on our website, Explaining the Urban-Rural Divide, How Obamacare and Medicaid Drive Voting, Lessons from the COVID-era Welfare Expansion, How race makes us less punitive on opioid policy, and How policymakers and experts failed the COVID test. Thanks to Michael Shepherd for joining me. Please check out Rural Pain, Republican Gain and then listen in next time.
