Physicians and politics.

In this issueof JAMAInternalMedicine,Bonicaandcolleagues1 provide for the first time, to our knowledge, a full description of the political campaign contributions of American physicians. Their rigorous analysis of campaign contributions for presidential and congressional elections over thepast 2decades showshow these contributions relate to the sex, specialty, income, andemploymentof eachphysician andhowthepolitical preferences of the profession have changed in recent years. This is an interesting study, although the results are largely predictable. Bonica and colleagues1 find a secular trend toward support ofDemocratic candidates; in recent 2-year election cycles, physicians’ support for Democrats was similar to that of thegeneral public. Therewas strongerDemocratic support among female physicians thanmale physicians, amajority of Democratic support among employed physicians, and muchmoreDemocratic contributions byphysicians in lowerpaid primary care specialties than by those in the higher-paid surgical and procedural specialties. Republican support was stronglycorrelatedwithmeanincomeof thespecialty,but there werenodata todeterminewhetheryoungconservatives chose those specialties or whether they became conservative after making their specialty choice. The authors are careful not to extrapolate much beyond their findings.Theirdata showarecent shift toward theDemocrats in the traditional physician support of Republicans, and they believe that this shift is likely to continue. However, thesedatamaynotbe representativeof the rank and file of physicians. The authors consider only contributions to individual candidates or party-connected organizations that total $200ormoreover anelectioncycle, the threshold for reporting to theFederalElectionCommission.With this limit, they found that only 2.6% of active physicians contributed to federal election campaigns in the 1992 election cycle andonly9.4%contributed in the2012electioncycle. It is a safe guess that the majority of physician contributions were less than $200 (like those of the general public), so we cannot be sure from this study which party most physicians really favored. Furthermore, there has recently been a large movement of solo practitioners and small partnerships into employment by institutions, such as hospitals, insurance plans, and physician-ownedmultispecialtymedical groups,2 which this analysis does not fully capture. The authors present data on aggregated physician contributions for fewer than 20 of the largest employers. On the basis of my discussion with a representative of the American Medical Group Association, the trade association representing more than 400 large practice groups, I estimate that large groupsmay employ one-third or more of all practicing physicians. These large employers undoubtedly influenced the political contributions of their employees, andwedonot knowhowmost of their contributions were distributed. Inaddition,Bonicaandcolleagues1describechanges inpatterns of campaign contributions that are so recent that predictionsof howphysicianswill behave in the future are at best uncertain. We simply do not know howmost physicians will react to theproblems thatwill probably emerge as theAffordable Care Act (ACA) plays out. Despite its initial benefits, the ACA leaves a substantial number of uninsured and underinsuredpeople in theUnitedStates, andbymostpredictions, the costs of public and private insurance will continue to increase at a rate that threatens thenational economy.3Will physicians remain passive? Will their political views remain the same as their patients' access to affordable health care is furthererodedbyrisingcosts?Andwillphysiciansallowtheir ability to function as autonomous but accountable professionals, whose practice is morally based, be compromised by the innumerableByzantine regulations andguidelines generatedby thecontinued implementationof theACAand itspossible later amendments? I hope not. Economic incentives in the ACA, and the feefor-service payment system that the ACA supports, still encourage thehighest-paid specialists to choose the statusquo.4 Nevertheless, I believe thatmostphysicianscareenoughabout the values of their profession to work for a better, more equitablehealthcare systemwhen theneedbecomesobvious.Provided that the new system ensures physicians of appropriate professional independence and fair compensation, most will want to see reform that corrects the ACA's failures.5 Furthermore, the newwave of female physicians, whowill soon representhalformoreofall activephysicians,willprobablychange attitudes in all the specialties, including the opinions of their male colleagues. The data show that female physicians favor Democratic candidates. Thus, I believe that female physicianswill expand the social outlookof theprofession, encourage it to become more liberal in its political views, and persuade it to consider how to replace the ACA with a better system. A new health care system that provides universal access and is affordable and efficientwill be difficult to achieve. The private insurers and all the other businesses that profit from the current commercial systemwill resist it.Major reformwill need wide public support, which in turn will rely on advocacy by themedical profession. But I believe that reformwill nevertheless be eventually enacted because itmeets awidely sharedandgrowingpublicdesire formore fairness inanAmericansocietypervadedby inequality inaccess togoodhealthcare andmany other social benefits. Physicianshaveuniquepower to reshape themedical care system. They arewhatmakes itwork and are best qualified to Author Audio Interview at jamainternalmedicine.com