How the opioid crisis turned places Republican

You can't give the right answer if you don't know the question.

Chris, a homeless heroin addict, pauses to shoot-up by a railway underpass in the Kensington section of Philadelphia which has become a hub for heroin use on July 31, 2017 in Philadelphia, Pennsylvania. Photo by Spencer Platt/Getty Images.

The opioid epidemic is responsible for more than 800,000 deaths in the U.S. alone. Arguably the single best policy response to prevent more deaths was Medicaid expansion, an Obamacare program that was opposed by Republicans at every turn. One study found that expansion states had an 11% lower rate of death involving heroin. Even now, when the politics have become nearly untenable, several Republican-led states are still turning down federal dollars to expand Medicaid.

And yet, in parts of the country most ravaged by the opioid epidemic, places where people have become more reliant on social services and, where it exists, expanded health care—those places have become more Republican.

Economists Carolina Arteaga and Victoria Barone just published a new paper in the Quarterly Journal of Economics showing that the opioid epidemic pushed the electorate right (It made a splash even in white paper form last year, so you may have already heard about it).

The upshot of the paper is that there is a causal relationship between the opioid epidemic and increased Republican vote share in gubernatorial, congressional, and presidential races over the past 30 years. When Purdue Pharma began rolling out OxyContin, it focused first on trying to win the cancer pain market and then expanded to noncancer patients in the same geographic areas. Therefore, cancer mortality rates in 1996 were a useful instrument to tease out the impact of opioid use on voting behavior.

The paper finds that higher rates of cancer deaths in 1996 made locations the target of Purdue Pharma’s initial wave of marketing, which led to significantly higher deaths, reliance on public assistance and social insurance programs, and a rising Republican share of the vote.By the 2022 midterms, one-standard-deviation-higher 1996 cancer mortality translated to a 4.5-percentage-point increase in the Republican vote share.

When I first saw this paper, I thought it was a counterintuitive finding. I don’t know if I had a prior on this in particular, but it wasn’t immediately obvious to me why the opioid epidemic — which I largely took as a public health and corporate malfeasance story — would induce people to vote Republican.

So what explains this effect?

Arteaga and Barone argue that voters understood the opioid epidemic as a crime, order, and, to a lesser extent, an immigration problem, not merely a public health emergency.

This isn’t … crazy? Most people aren’t addicted to opioids, nor are they especially worried about becoming addicted. But they do notice an uptick in drug overdoses in their community, particularly if they’re happening in public. And the resulting economic impact is felt much more broadly than the direct health effects that are concentrated within families.

Notably, there is research showing that people close to opioid victims are themselves more likely to shift to the left — Republicans were 25% more likely to defect from their party than the statewide average Republican, while Democrats saw no such effect.

The economists included a second act in their paper in which they show how right-leaning media was both more responsive in covering the opioid epidemic and more likely to frame it “primarily in terms of crime, disorder, and illegal drug trafficking.”

The authors provide suggestive evidence that people became broadly disenchanted by what they saw as Democrats’ soft-on-crime-and-disorder policies. For one, increased exposure to the opioid epidemic predicts lower support for marijuana legalization. They also observe greater support for increasing the number of police officers on the street in places where Purdue Pharma first began pushing OxyContin.

I don’t think this is a matter of brainwashing by right-wing media. Yes, I think the media helped provide a narrative that was conducive to a reactionary law-and-order politics, but voters aren’t blank slates, narratives stick when they have a tangible relationship to reality.

There’s a lot more to this paper, which I talked about with Arteaga on today’s podcast, but I want to zoom out for a moment, because this phenomenon isn’t constrained to the opioid epidemic. Time and again, political professionals assume that their frame for understanding an issue is the primary one, stubbornly sticking to an analysis of root causes, only to find out voters are speaking a completely different language.

Parlez-vous français?

Before you can provide a policy response to a problem, you have to agree on what the problem actually is. Much of politics happens at this level of debate, but so much explicit policy discourse is happening at the level of solutions, which, of course, presumes that you have not only identified a common problem but also a commonly desired outcome.

When voters are frustrated with the opioid epidemic, a significant number of them actually are referring to the crime, disorder, and economic consequences, not the public health aspects. But looking more broadly, this same problem has cropped up in other places. Let’s take two issues that have been top of mind for the public — when voters say they are worried about democracy or immigration, what are they actually saying?

During an April 2024 campaign event, then-President Joe Biden argued that, despite the press’s skepticism about his focus on democracy, the public agreed with his warning that American democracy was at stake: “60 percent of the people agreed with me. Our democracy literally is at stake.” Biden framed the threats to democracy as embodied by Trump, invoking Jan. 6 and his attacks on abortion rights.

But the public was actually pretty divided on what those threats to democracy really were.

In a New York Times/Siena College poll conducted in October 2024, 76% of voters agreed that “American democracy is currently under threat”, including 77% of would-be Harris voters and 76% of would-be Trump voters. The survey then asked respondents to provide one or two words summarizing the threat to democracy.

Harris voters, like Biden, largely pointed to Donald Trump, but Trump voters and unaligned voters were more likely to point broadly to corruption, politicians in general, as well as immigrants.

An AP-NORC poll from a few months earlier found that 87% of Democrats and 54% of independents believed a second Trump term would negatively affect U.S. democracy. But 82% of Republicans and 56% of independents believed the same about Biden.

Immigration is another issue where there is significant confusion about what exactly voters are mad about. Are they mad at the number of immigrants entering the country? Are they upset because these immigrants are raising their home prices? Are they mad because they think they are, uh, eating cats and dogs?

The Argument’s polling indicates that immigration is largely a crime problem. A majority of voters told us they would support more legal immigration as long as there was close vetting to prevent criminals and terrorists from entering the country.

But so many people in Washington continue to take it as obvious that people are mad about immigration because of the purported economic costs. The empirical argument here is incredibly weak, so this isn’t a case of wonk-brained liberals running amok (also because right wing thinkers are more likely to deploy these sorts of arguments). Rather, it’s that the economic frame is the default language of the policy class on both sides. It feels rigorous, measurable, and it maps onto familiar left-right debates about wages and welfare spending.

But voters aren’t arguing about labor-market elasticities, they’re reacting to disorder: asylum seekers sleeping on sidewalks, mayors announcing funding diversions from popular programs to migrant care, a general sense that nobody is in charge. As I reported a couple of years ago, the size of migrant flows does not do a good job of predicting where backlash pops up: “Americans do not have some instinctive sense of the number of border crossers, but they do notice asylum seekers sleeping on the streets and their mayors announcing funding diversions from popular programs to migrant care.”

This is a big reason why voters are turning on Trump and the Republican Party. Now, the chaos is caused by the immigration enforcement regime.

The stakes of these misunderstandings are high. Both because there are serious, material harms that Medicaid expansion alone could not address and because democracy only works if the populace can accurately transmit its concerns and desires to its elected officials.

One finding from the opioid paper that I glossed over was that left-leaning media was remarkably unresponsive to the opioid crisis. Higher rates of opioid-related deaths led to higher rates of coverage in right-leaning media, but not so for the left. Moreover, the authors find that Fox News covered opioid epidemic stories at 1.5 times the rate of CNN and 1.7 times that of MSNBC.

“I have missed something.”

One of my favorite classes I took in college was about American fiction in the early 20th century. It introduced me to a bunch of authors like Willa Cather and Flannery O’Connor, but one book stuck out to me most: Winesburg, Ohio by Sherwood Anderson.

One of the prominent themes we explored in the class was how insufficient language can be at facilitating communication, and yet, despite this, the best response is to keep trying. In Winesburg, which is more a collection of related stories than a novel, Anderson tells the story of a teacher, Kate Swift, who sees in her student, George, “the spark of genius” and tries desperately to communicate to him that he must become a writer.

Kate is in despair trying to explain herself to him, at one point crying out “What’s the use? It will be ten years before you begin to understand what I mean when I talk to you.”

George thinks she’s in love with him and, to be fair, she does then get … physically intimate with him¹, after which she freaks out and leaves, seemingly frustrated at her inability to get through to her student. The story ends with George tossing and turning, trying to suss out what happened: “I have missed something. I have missed something Kate Swift was trying to tell me.”

I have a real soft spot for George here. He falls into a fitful sleep, still trying to figure out what he had missed. Unlike Kate, he doesn’t give up, doesn’t resign himself to misunderstanding, or fool himself into thinking his version of events, his framing is all there is.

1. Maybe she sleeps with him? Anderson is a bit vague. Here’s the relevant passage:

“In the newspaper office a confusion arose. Kate Swift turned and walked to the door. She was a teacher but she was also a woman. As she looked at George Willard, the passionate desire to be loved by a man, that had a thousand times before swept like a storm over her body, took possession of her. In the lamplight George Willard looked no longer a boy, but a man ready to play the part of a man. The school teacher let George Willard take her into his arms. In the warm little office the air became suddenly heavy and the strength went out of her body. Leaning against a low counter by the door she waited. When he came and put a hand on her shoulder she turned and let her body fall heavily against him.”