The Wall Street Journal - 07.10.2019

A12| Monday, October 7, 2019 THE WALL STREET JOURNAL.

most physicians say they don’t

support Republican lawmakers’

calls to repeal it without a clear

replacement since they have al-

ready invested in adapting to

its mandates, and because re-

peal could leave millions unin-

sured.

“The Republican Party has

changed,” said A. Patrice Bur-

gess, a 55-year-old Boise family

physician. The lifelong Republi-

can voted for Democrats in the

past two presidential elections

in part because she didn’t want

the ACA dismantled, and be-

cause Mr. Trump’s behavior ap-

palled her.

Age factor

Research led by Adam Bon-

ica, associate political science

professor at Stanford Univer-

sity, shows that younger male

and female physicians are sig-

nificantly more liberal than

older ones, a divide that is gen-

erational and not simply a

function of partisanship chang-

ing as doctors age. Physicians

say medical schools have

played a role in this by broad-

ening who they admit and what

they teach in a way that favors

Democratic ideals.

Prof. Bonica’s and other re-

search shows that lower-paid

doctors such as pediatricians

and internists favor Democrats

while higher-paid ones like sur-

geons and anesthesiologists fa-

vor Republicans.

The profession’s shifting

politics were on display in Chi-

cago in June when hundreds of

doctors gathered for the AMA’s

annual meeting. The most con-

tentious 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 meet-

ing’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 law-

makers 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 ta-

ble from the start.”

Donald J. Palmisano, a for-

mer AMA president, warned

the group of stories he had

heard from physicians in Can-

ada and Great Britain, which

have nationally run health sys-

tems. Patients died while sit-

ting on waiting lists for treat-

ments, he said. Government

regulations stifled physician in-

novation. “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

parities that favor hospitals

over small practices.

“The last decade has seen a

historic intrusion of govern-

ment 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 gov-

ernment, according to the

AMA.

The AMA describes itself as

a nonpartisan organization,

and only a fraction of practic-

ing physicians make up its

250,000 members. It ranks

among the top 10 lobbying en-

tities in Washington and spent

more than $20 million last

year, according to the Center

for Responsive Politics.

Its political-action commit-

tee, AMPAC, also spends about

$1 million a year to help elect

or defeat congressional candi-

dates. 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.

Many physicians say the Re-

publican 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

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 amend-

ment failed by a narrow 47-

margin, it sent murmurs of sur-

prise through the ballroom.

Other changes adopted at the

meeting included support for

curbing anti-transgender vio-

lence; combating the criminal-

ization of homelessness; and

expanding insurance subsidies

for low earners under Obama-

care.

The Trump administration

dispatched a top health official

to emphasize its support of

doctors and condemn Medicare

for All. Seema Verma, adminis-

trator of the Centers for Medi-

care and Medicaid Services,

told the group the administra-

tion’s “Patients over Paper-

work” 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 dis-

Shareofphysiciansbyparty

identification

40

0

10

20

30

%

2011 ’12 ’

Democratic

Republican

Independent

Shareofphysicians'political

contributions

80

20

30

40

50

60

70

%

1990 2000 2010

MovingLeft

MorephysiciansnowidentifyasDemocrats,anddoctors

contributemoremoneytoDemocratsinfederalelections.

Morephysiciansarenowemployeesinsteadofownersoftheir

ownpractices,andmorewomen,whoaremorelikelytobe

Democrats,arenowdoctors.

Shareofphysiciansbytype

60

0

15

30

45

%

2012 ’14 ’16 ’

Owner

Employee

Contractor

Note: Percentages may not add up to 100 due to rounding.

Sources: Gallup (party ID); Center for Responsive Politics (political contributions); American

Medical Association (employment type); American Community Survey (gender)

Shareofphysiciansbygender

100

0

25

50

75

%

2006 ’08 ’10 ’12 ’14 ’

MaleMale

FemaleFemale

TikTok

Gives Life

To Old Hits

FROM PAGE ONE

Luis Seija, an internal medicine-pediatrics resident, made a home visit to a patient in New York.

SARAH BLESENER FOR THE WALL STREET JOURNAL

‘I don’t have the same interests as someone who’s in independent practice,’ said Dr. Jane Zhu, who works for a large health system.

business-owner physicians who
back the GOP for its pro-em-
ployer policies.
In addition, many doctors
today start their careers with
hundreds of thousands of dol-
lars in student debt and little
hope of earning the outsize in-
comes their predecessors did a
generation ago.
The result is a fundamental
leftward realignment of a polit-
ically powerful professional
group, one that has been accel-
erated by recent politics, in-
cluding 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 pa-
tients and how they influence
the 2020 presidential race. It’s
part of a larger turn among
white-collar Americans toward
the Democratic Party.
In 1990, 61% of national po-
litical campaign contributions
by physicians went to Republi-
cans, while 38% went to Demo-
crats, 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 contri-
butions going to Democrats
while one-third went to Repub-
licans.
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 Dem-
ocratic side,” said David J.
Rothman, a professor of social
medicine at the Columbia Uni-
versity Vagelos College of Phy-
sicians and Surgeons who stud-
ies 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 ex-
pand reproductive health ser-
vices. And some are backing
Democratic proposals to create
a U.S. single-payer health sys-
tem.
Last year, the share of physi-
cians 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 inter-
ests as someone who’s in inde-
pendent practice,” said Jane
Zhu, a 34-year-old who is em-
ployed as an internal medicine
physician at a large health sys-
tem in Portland, Ore. When she
isn’t seeing patients, Dr. Zhu
researches ways to improve ac-
cess to care for vulnerable pop-
ulations, 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 physi-
cians accelerated in 2016, when
Donald Trump clinched the Re-
publican presidential nomina-
tion.
Voters with four-year col-
lege 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 Republi-
cans’ 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,

Continued from Page One

spite limiting songs to 15 sec-
onds. So popular is the app
that it has pulled along old
songs, obscure songs and oth-
ers lost to time.
A video of a girl crying and
dancing to Mariah Carey’s
2009 song “Obsessed” rode a
wave of popularity this sum-
mer on a range of social-media
platforms after it was posted
to TikTok, where it has 2.5 mil-

Continued from Page One

lion likes and counting. That

spurred others to make varia-

tions.

In one version, Howie Man-

del’s daughter teaches him the

dance. Students in another per-

form it in class to avoid deten-

tion. Ms. Carey herself did her

own take walking down the

street after her car broke

down.

Last week, “Obsessed” ap-

peared on Billboard’s R&B

Streaming chart at No. 23, one

day shy of a decade after the

song’s album was released.

Those charts count listens

from music subscription ser-

vices and platforms like You-

Tube, but not TikTok.

The song has since dropped

off the chart, but its appear-

ance and the app’s growing

ability to drive music discovery

is “a natural byproduct” of the

format, said Corey Sheridan,

TikTok’s head of music content

operations.

“People see all these memes

and remember a song they for-

got about. And of course then

they’ll go to Spotify or Apple

Music and listen to it there,”

said Trevor Anderson, Bill-

board’s R&B and hip-hop

charts manager.

He’s done it himself. “ ‘9 to

5’ has really come back around.

Who doesn’t love a good, clas-

sic Dolly record?” he said.

TikTok has been a source of

new hits—the most famous be-

ing “Old Town Road” by Lil

Nas X, which got its start on

the platform and went on to

become the longest-reigning

No. 1 hit on the Billboard Hot

100.

The TikTok resurgences, by

contrast, have swept up artists

from Justin Bieber to Louis

Prima, who got his start in the

1930s swing era. On TikTok,

people pretend to be time trav-

elers to a remix of his song “I

Wan’na Be Like You” from

1967’s “The Jungle Book.”

The opening line to Elton

John’s 1970 “Your Song” serves

as the reveal for videos where

one person finds something

amusing but their friends

don’t. Videos of cats perform-

ing to the Chordettes’ “Mr.

Sandman” on a delay have

found an audience as well.

Helen Park, a 27-year-old

high-school band teacher in

Greenville, N.C., initially down-

loaded the app over the sum-

mer to be able to relate to her

students. She went viral with a

video calling her students out

for being on TikTok instead of

practicing their instruments.

She’s ended up rediscover-

ing some old songs, including

Chris Brown’s “Look at Me

Now,” which she used in a

video of her guinea pig eating.

When users open up TikTok

on their phones, they are im-

mediately served up a full-

screen video. It’s a call to ac-

tion: You either watch it or

stop it. Tap, it’s paused. Swipe,

there’s another video. And an-

other. No account necessary.

The app’s algorithm refines its

recommendations on its “For

You” page based on your en-

gagement with previous videos.

TikTok doesn’t provide a

clear prompt on how to use it

or what to use it for. The ap-

proach has led to a genera-

tional divide where younger

users intuit the design, while

many older users are left

scratching their heads.

For those on the app, “the

older kids have heard a song a

while ago and the younger kids

hear it for the first time.

There’s definitely a cycle,” said

Mr. Drennan, the 19-year-old

who rediscovered “Fergali-

cious” on TikTok.

He makes his own videos as

well, including of him tap

dancing to viral songs. He’s

now made two videos using

Ms. Carey’s “Obsessed.” Before

TikTok, he said, “I’d never

heard it.”

capability this country has.”

Conservative doctors also la-

ment that Republicans haven’t

used their time in power to do

more for the profession.

“The Republicans, when

they’ve had their chance to re-

ally affect health care, they’ve

been all over the board,” Dr.

Gill said.

Eitan Hersh, an associate

professor of political science at

Tufts University, and Matthew

Goldenberg of Yale surveyed

primary-care physicians to de-

termine whether their political

beliefs influenced their treat-

ment 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 pa-

tient had guns in their home.

Geographical divide

Prof. Bonica and co-authors

studied where new doctors

move after residency and found

they look for an “ideological

fit.” The researchers deter-

mined that a liberal physician

residing in a conservative area

is about twice as likely to relo-

cate as a conservative physi-

cian 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 profes-

sionals but is striking in medi-

cine 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.

“You are not a wealthy person

in New York if you are a physi-

cian,” 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 prac-

tice at the border of Texas and

Mexico in the middle of no-

where make more money than

anybody else,” she said. But she

and her husband, who is In-

dian, 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 un-

dergraduate 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 resi-

dents.

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 stu-

dent loans and no interest in

owning his own practice. His

favorite presidential candidate

is former Democratic represen-

tative Beto O’Rourke, a fellow

Texan whom he admires for re-

turning to El Paso and becom-

ing civically active.

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.”

Doctors

Move Left

Politically

LEAH NASH FOR THE WALL STREET JOURNAL