Date Published: June 10, 2019
Publisher: Public Library of Science
Author(s): Adam Bonica, Howard Rosenthal, David J. Rothman, Sean Eric Richey.
Although a substantial literature considers physician advocacy fundamental to medical professionalism, only a minority of physicians actually pursue it. We analyze the characteristics of 6,402 physicians who engaged in political advocacy by signing the Clinician Action Network’s 2016 petition objecting to the American Medical Association’s endorsement of the nomination of Tom Price as Secretary of Health and Human Services. These physicians were matched to the NPI (all physicians) and PECOS (largely Medicare payment recipients) directories. Physicians in the directories were matched to publicly disclosed campaign contributions. Contributions are used to measure political preferences expressed on a liberal-conservative scale. We document a pronounced generational realignment in the politics of the medical profession, with recent graduates trending sharply Democratic. Petition signing vs. non-signing is responsive to gender, specialty, geographic location, personal liberal-conservative preferences and year of graduation from medical school. Petition signers were more likely to be women (62% of signers versus 34% of non-signers), recent medical school graduates (58% of signers versus 42% of non-signers), and in lower-paying specialties (27% of signers versus 12% of non-signers). The changing face of physician advocacy has important implications for understanding how the medical profession is likely to influence health care policy in coming decades.
Recent research has emphasized that physicians have become polarized in their political preferences as reflected in their party registrations and contributions , , . Hersh and Goldenberg  have shown that physician’s political beliefs inform their professional decisions regarding patient care. In contrast, we know surprisingly little about physicians who conduct political advocacy, who they are by age, sex, specialty, employment, and geography. Survey research indicates that most physicians consider advocacy part of their professional duties . However, only approximately one-quarter of them pursue the activity . To better understand the characteristics of physicians who do engage in advocacy and to assess its future prospects, we studied the 6,401 physicians who in 2016 signed a public petition objecting to the nomination of Tom Price for Secretary of Health and Human Services (HHS). To be sure, signing a petition is not as demanding as testifying before government committees or helping organize a grass roots movement. However, taking such a stand demonstrates a readiness to express and act on a political position.
Over the past three decades, data on contributions to presidential and congressional elections indicate that physician party alignment has shifted from a large majority supporting Republican candidates to two sharply divided blocs, with a small majority supporting Democrats . The partisan divisions strongly correlate with sex and specialty; women in lower paying specialties—such as internal medicine, pediatrics, and psychiatry—are far more likely to contribute to Democratic candidates. So too are physicians working in not-for-profit organizations. It is also noteworthy that more recent graduates of medical schools tend to make campaign contributions to Democrats (see Fig 1); that is, younger physicians are much more likely to be Democrats than older ones.
We matched the 6,401 signatories to the NPI (National Provider Information, downloadable from NPPES, the National Plan and Provider Enumeration System) and PECOS (Medicare Provider Enrollment, Chain, and Ownership System) databases. They were further matched to campaign contribution records from the Database on Ideology, Money in Politics, and Elections (DIME), which combines and standardizes data from the Federal Election Commission and state reporting agencies . Both the NPI and PECOS provide information about the sex, employment, specialty, and geographic location of the physician . PECOS also provides information about the year the physician graduated from medical school, which can be used to study cohort effects. PECOS covers about two-thirds of the physicians in NPI. The difference is mainly one of PECOS not including physicians not receiving Medicare payments. Although PECOS underrepresents pediatricians and some other specialties, the relationship of political behavior to sex, employment, specialty, and geographic location is highly similar when comparing NPI and PECOS.
The 6,401 physicians who went public in their advocacy to oppose the Price nomination were exceptionally young and female and tended to live in “blue” parts of the country. Those who donated overwhelmingly gave to Democrats, and particularly to liberal Democrats. Hence, it is not surprising that they signed the Clinician Action Network’s objection to Price’s policy preferences on Medicaid, CHIP, and Medicare.
The Clinical Action Network petition was motivated by the AMA endorsement of Tom Price. Signers of the petition manifested “activism” not just in signing but also in being more likely, compared to other physicians, to contribute money to political campaigns. The contributions demonstrated that the signers were likely to be politically liberal or progressive. The petition, through its signers, is indicative of political diversity in a profession that was historically conservative. Political tension within the profession has been reflected in the positions taken by the AMA. After endorsing Price, a strong opponent of Obamacare, the AMA later opposed repeal.