The historic shift, driven by changes in the business of medicine and women entering the profession, comes with the overall movement of college-educated people to the Democratic Party. The realignment is changing where physicians live and work, how they treat patients and how they influence the...
Historic shift, driven by changes in business of medicine and women entering profession, comes with overall movement of college-educated people to Democratic Party.
Doctors used to be America’s quintessential Republicans. During the 20th century, most were high-earning men who owned their own practices. They liked Republicans’ support for curbing medical malpractice lawsuits and limiting government’s role in health care. When Democrats proposed creating Medicare in the 1960s, the American Medical Association, the largest physician group then and now, opposed the idea with a campaign starring then-actor Ronald Reagan.
In the decades that followed, medical schools started accepting greater numbers of women, who are more likely to be Democrats (women today account for nearly half of U.S. medical students). Consolidation and the cost of new technology made it harder to own a small practice. Older physicians sold theirs, and new ones didn’t want to hang their own shingle, so they became employees of health systems. The result is fewer business-owner physicians who back the GOP for its pro-employer policies.
In addition, many doctors today start their careers with hundreds of thousands of dollars in student debt and little hope of earning the outsize incomes their predecessors did a generation ago.
The result is a fundamental leftward realignment of a politically powerful professional group, one that has been accelerated by recent politics, including doctor opposition to repealing the Affordable Care Act and unease some doctors express about President Trump. This phenomenon is changing where physicians choose to live and work, how they treat patients and how they influence the 2020 presidential race. It’s part of a larger turn among white-collar Americans toward the Democratic Party.
‘I don’t have the same interests as someone who’s in independent practice,’ said Dr. Zhu, who works for a large health system. Photo: Leah Nash for The Wall Street Journal
In 1990, 61% of national political campaign contributions by physicians went to Republicans, while 38% went to Democrats, according to a Wall Street Journal analysis of data from the Center for Responsive Politics. By last year, those numbers had essentially flipped, with nearly two-thirds of physician campaign contributions going to Democrats while one-third went to Republicans.
A 2016 Gallup poll found that 35% of doctors considered themselves Democrats while 27% were Republicans and 36% identified as independents.
“More or less over a 20-year period, a profession that was always thought of as rock-ribbed Republicans has changed, and tilted to the Democratic side,” said David J. Rothman, a professor of social medicine at the Columbia University Vagelos College of Physicians and Surgeons who studies physician partisanship. “That’s a big deal.”
Doctors are clustering in big cities where other Democrats reside, exacerbating a shortage of physicians in rural areas. They are urging lawmakers to restrict firearm access and expand reproductive health services. And some are backing Democratic proposals to create a U.S. single-payer health system.
Last year, the share of physicians who work as employees surpassed the portion that owns their practice for the first time, according to the AMA.
“I don’t have the same interests as someone who’s in independent practice,” said Jane Zhu, a 34-year-old who is employed as an internal medicine physician at a large health system in Portland, Ore. When she isn’t seeing patients, Dr. Zhu researches ways to improve access to care for vulnerable populations, and she led a group of physicians in opposing the nomination of President Trump’s first health and human services secretary, Tom Price.
The political drift of physicians accelerated in 2016, when Donald Trump clinched the Republican presidential nomination.
Voters with four-year college and advanced degrees moved toward the Democratic Party, while those without a college degree flocked to the GOP and helped put Mr. Trump in the White House.
Many physicians say they were uneasy about Republicans’ health policy proposals and turned off by Mr. Trump’s stance on scientific issues, such as his skepticism about climate change. Despite having mixed feelings about Obamacare, most physicians say they don’t support Republican lawmakers’ calls to repeal it without a clear replacement since they have already invested in adapting to its mandates, and because repeal could leave millions uninsured.
“The Republican Party has changed,” said A. Patrice Burgess, a 55-year-old Boise family physician. The lifelong Republican voted for Democrats in the past two presidential elections in part because she didn’t want the ACA dismantled, and because Mr. Trump’s behavior appalled her.
Research led by Adam Bonica, associate political science professor at Stanford University, shows that younger male and female physicians are significantly more liberal than older ones, a divide that is generational and not simply a function of partisanship changing as doctors age. Physicians say medical schools have played a role in this by emphasizing social issues in who they select and what they teach.
Prof. Bonica’s and other research shows that lower-paid doctors such as pediatricians and internists favor Democrats while higher-paid ones like surgeons and anesthesiologists favor Republicans.
The profession’s shifting politics were on display in Chicago in June when hundreds of doctors gathered for the AMA’s annual meeting. The most contentious topic was whether to loosen the group’s longstanding opposition to creating a single-payer health-care system.
Protesters who support such a system disrupted the meeting’s opening session, storming into the hotel ballroom where it took place. Medical students proposed removing language opposing single payer from the AMA’s policy positions because they feared it would cause lawmakers to exclude them from the debate.
“There’s a whole bevy of proposals in Washington right now,” said Joy Lee, a recent medical school graduate who is interning at a Boston health system, as she stood before doctors inside the ballroom. “We need to be there at the table from the start.”
Donald J. Palmisano, a former AMA president, warned the group of stories he had heard from physicians in Canada and Great Britain, which have nationally run health systems. Patients died while sitting on waiting lists for treatments, he said. Government regulations stifled physician innovation. “We ought to put a stake in the heart of single payer,” he told the group.
New AMA leaders cautioned against dismissing the idea. “We should have fair-minded debate about single payer and Medicare for All,” Patrice A. Harris, an Atlanta psychiatrist and the president of the AMA, said in an interview.
In a series of votes, the AMA delegates opted to keep their written opposition to single payer, but when one amendment failed by a narrow 47-53 margin, it sent murmurs of surprise through the ballroom. Other changes adopted at the meeting included support for curbing anti-transgender violence; combating the criminalization of homelessness; and expanding insurance subsidies for low earners under Obamacare.
The Trump administration dispatched a top health official to emphasize its support of doctors and condemn Medicare for All. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, told the group the administration’s “Patients over Paperwork” initiative had reduced burdensome regulations that eat up doctors’ time. She said the administration is working to lower drug prices, simplify how Medicare pays doctors and eliminate reimbursement disparities that favor hospitals over small practices.
“The last decade has seen a historic intrusion of government into the delivery [of] care and the practice of medicine,” she said. “As physicians on the front lines, you are stuck in the middle of all of this.”
Some doctors at the meeting said the Trump administration is part of that intrusion. The AMA earlier this year filed suit to block the administration from limiting physicians’ ability to refer patients to abortion providers when they are treated through the Title X low-income health program, citing “the administration’s overreach and interference in health-care decision making.” It was only the third time in the past two decades that the group has sued the federal government, according to the AMA.
The AMA describes itself as a nonpartisan organization, and only a fraction of practicing physicians make up its 250,000 members. It ranks among the top 10 lobbying entities in Washington and spent more than $20 million last year, according to the Center for Responsive Politics.
Its political-action committee, AMPAC, also spends about $1 million a year to help elect or defeat congressional candidates. For most of the 1990s and 2000s, AMPAC donated more to Republicans. In 2018, it split its contributions almost evenly between the two major parties, according to figures from the center. Dr. Harris said AMPAC’s goal is to affect a wide range of health-care issues, and that no party has an exclusive claim to patients’ best interests.
Many physicians say the Republican Party and the Trump administration still support their interests. “They’re open to suggestions and hearing ideas on how to cut red tape,” said John T. Gill, a 63-year-old orthopedic surgeon in Dallas and a Republican. Ray Callas, a 50-year-old Beaumont, Texas, anesthesiologist who is also a Republican, said that President Trump “showed the economic capability this country has.”
Conservative doctors also lament that Republicans haven’t used their time in power to do more for the profession. Such complaints date back to the mid-2000s, when then-Senate Majority Leader Bill Frist, a surgeon, failed to help pass a medical malpractice overhaul.
“The Republicans, when they’ve had their chance to really affect health care, they’ve been all over the board,” Dr. Gill said.
Dr. Frist said in an email that medical malpractice legislation he brought to the floor five times was defeated by the trial lawyer lobby, and that states including Texas successfully overhauled their malpractice laws.
Research suggests physicians’ political ideology impacts Americans’ medical care. Eitan Hersh, an associate professor of political science at Tufts University, and Matthew Goldenberg of Yale surveyed primary-care physicians to determine whether their political beliefs influenced their treatment decisions. They found that Republican doctors were more likely to discuss the health risks of marijuana and urge patients to cut down. Democratic doctors were more concerned about whether a patient had guns in their home.
Prof. Bonica and co-authors studied where new doctors move after residency and found they look for an “ideological fit.” The researchers determined that a liberal physician residing in a conservative area is about twice as likely to relocate as a conservative physician who lives there, and vice versa.
As young physicians have become more liberal, they are increasingly settling in urban areas filled with like-minded residents—a pattern that is true for many young professionals but is striking in medicine because it works against doctors’ financial interests. For primary care doctors, salaries in New York and Washington are among the lowest in the nation despite the cities’ high cost of living, according to Prof. Bonica.
Hilary E. Fairbrother, a Democrat, grew up in Helena, Mont., went to medical school in Atlanta and trained as an emergency physician in New York City. When it came time to find her first job, she spoke to a hospital in her hometown and learned she could start out making $350,000 a year as an attending emergency physician there. But instead, she took a comparable job in Brooklyn paying $165,000 because she was young and single and wanted to live in a big city.
That decision came at a cost. “You are not a wealthy person in New York if you are a physician,” she said.
Dr. Fairbrother got married and two years ago she and her husband decided to move to Texas to be closer to his family. “My friends who go and practice at the border of Texas and Mexico in the middle of nowhere make more money than anybody else,” she said. But she and her husband, who is Indian, didn’t want to live in a small town.
“What happens when there’s no Indian restaurants where we live and my child never gets to taste Indian food?” she asked. The couple settled in Houston, where Dr. Fairbrother, 40, earns $288,000 a year treating ER patients and directing undergraduate education at a teaching hospital.
Prof. Bonica predicts the geographic maldistribution of physicians likely will get worse, potentially resulting in poorer health outcomes for rural residents.
Luis Seija is a 27-year-old medical school graduate who recently started an internal medicine-pediatrics residency at a New York City hospital. He has more than $170,000 in student loans and no interest in owning his own practice. His favorite presidential candidate is former Democratic representative Beto O’Rourke, a fellow Texan whom he admires for returning to El Paso and becoming civically active.
As a child, Dr. Seija struggled with respiratory infections and said his own pediatrician made a big difference in his life by helping his single mother navigate his care.
As the single-payer debate unfolded at the AMA meeting, Dr. Seija said he thought the concept was worth exploring. “It’s time for change.”