By Joseph Karlesky

and Berwood Yost

The debate over health care exposes a curious divide between votes on Capitol Hill and attitudes about reform among voters. The partisanship between Republicans and Democrats in Congress is much more intense than it is among voters themselves. Even more intriguing is that the divide between Capitol Hill and citizens is much sharper now than it was during the first great change in American health-care policy, the enactment of Medicare in 1965.

Congress was not always so superheated by partisanship and polarization as it is now. The establishment of Medicare in 1965 initiated a fundamentally new public policy that continues to touch millions of ordinary Americans and attract their overwhelming political support. When it was created, the program encountered harsh criticism and considerable opposition, but in sharp contrast to today, a substantial portion of the minority party in Congress supported it.

Social Security Online shows that in 1965, the House passed Medicare by a 307-116 vote. Measuring bipartisanship as the proportion of the minority party that cast a "yes" vote and agreed with the majority, 51 percent of voting Republicans (the minority party) supported Medicare. In the Senate, Medicare passed by a 64-30 vote. Of voting Republicans, 29 percent supported Medicare.

In the current debate about health-care reform, the House passed a bill in early November by a 220-215 vote. Only one Republican out of 177 voted "yes." The Senate bill passed last week was supported exclusively by 58 Democrats and 2 independents. Not a single Republican senator voted for the measure. A health-care bill that eventually passes both chambers may attract more GOP supporters, but the words and votes so far do not augur well for greater bipartisanship.

This stark divide on Capitol Hill is not reflected among Republicans and Democrats who responded to a recent Franklin & Marshall College Poll. The poll found that Democrats favor a series of reform proposals by approximately a 2-to-1 ratio over Republicans. Substantial numbers of Republicans, ranging between 30 percent and 43 percent, favor reforms such as expanding Medicare to everyone who does not have health insurance and requiring everyone to join a health-insurance plan.

A Gallup Poll conducted in September 1964 (now found in the iPoll Databank at the Roper Center for Public Opinion Research at the University of Connecticut) shows what the voters thought before President Lyndon Johnson signed the Medicare measure: 75 percent of Democrats and 37 percent of Republicans favored Medicare, a breakdown that is surprisingly similar to the division between Republicans and Democrats on the recent Franklin & Marshall poll.

Party polarization on Capitol Hill has pointedly increased between 1964 and 2009, yet voter attitudes on health care remained the same in polls taken 45 years apart. The paucity of Republican support in Congress in 2009 for proposals that a significant group of GOP voters favor highlights a hardening in procedures on Capitol Hill that is not rooted in changes in voter attitudes.

Among the explanations for this hardening are the rewards that gerrymandering of congressional districts confers on more ideologically pure members and the shifting geographical bases of the parties that weaken the leavening effects of intraparty differences. And, of course, with the immense amounts of money at stake in the health-care debate, the intensity of interest-group pressures playing on Capitol Hill can blur the relationship between congressional votes and attitudes among voters.

How faithfully representatives reflect constituency preferences is an old question in the study of politics. In the current debate over health care, this old question comes with the reminder that James Madison's warning about the mischiefs of faction is even more compelling.