Politics and health have a long, tangled history in the U.S. Of course, there’s the 1973 Supreme Court case Roe v. Wade.
Sarah WEDDINGTON: This is a fundamental interest on behalf of the woman that it is a constitutional right. And second —
Byron WHITE: Well yes, but how about the fetus?
WEDDINGTON: Okay, and second —
And then, more recently, there was the highly political, very heated debate on the Affordable Care Act, which finally passed in 2010.
Paul RYAN: This bill, more than any other decision we’re going to make in this body, will do more to put millions of Americans as dependents of a state rather than being dependent upon themselves.
So, politics have clearly always been a part of laws that affect our health. But what about the politics of our doctors? When we’re sick, how does a doctor’s political views affect the treatments they recommend?
From the Freakonomics Radio Network, this is Freakonomics, M.D.
I’m Bapu Jena. I’m a medical doctor but I’m also an economist. Each episode, I dissect an interesting question at the sweet spot between health and economics.
Today: the first of two episodes where I ask: how does a doctor’s political views affect their care? And what does that mean for patients?
Eitan HERSH: Doctors, just like any other person in a decision-making job, sometimes have to come kicking and screaming into the realization of their implicit biases.
There are a lot of ways that politics, in general, could affect how doctors treat patients. The first is through laws that doctors have to follow, regardless of their politics. Those laws can govern treatments, like whether doctors can provide abortions, or in some cases can govern their speech — like what doctors can counsel their patients about.
HERSH: Doctors generally want the freedom to talk to their patients about whatever they want, particularly if they think it’s medically relevant.
That’s Eitan Hersh. He’s a political scientist at Tufts University who researches political behavior. That freedom he’s talking about — of doctors talking to their patients about whatever they’d like — that’s mostly what patients want too. A lot of us probably even assume that when we go to the doctor, they’re going to tell us whatever we need to know — as Eitan says, whatever’s medically relevant. But … that doesn’t always happen.
HERSH: In some cases, you have state legislatures saying, you know, “Actually, we get to regulate the licenses here, or we get to regulate some aspects of medical care. And we do and don’t want you talking about certain things.” And those things tend to be politicized things.
There is a court case from Florida that really gets at what Eitan is talking about.
It started in 2010, when a 26-year-old mother of three took her youngest child to a pediatrician. The doctor asked if there were guns in the house. But the mother wouldn’t answer. So, the doctor refused to treat the family. The American Medical Association does encourage doctors to ask about how guns are stored in homes, by the way, and the doctor in this case felt that the mom’s refusal meant he couldn’t properly care for her child. Anyway, the story made its way through the media and to the state legislature, where policy makers had heard similar stories. The outcome? In 2011, Florida passed a law limiting how doctors could talk to their patients about guns. Doctors and doctor groups sued because they believed the law violated the First Amendment. And in 2017 a federal court overturned parts of the Florida legislation.
Laws can also restrict what treatments doctors can offer patients. For years, state lawmakers have been trying to place greater restrictions on reproductive health. Texas recently banned abortions once a fetal heartbeat can be detected, which could be as early as six weeks.
HERSH: Politics is entering the conversation here quite clearly when it comes to what patient care is supposed to be and who gets to decide that.
So, one way that politics influences the way doctors treat patients is through the laws doctors have to follow, regardless of what political beliefs they may have. But what if your doctor is a conservative or liberal? Might their political beliefs, their outlook on the world, influence how they treat you? Or, can doctors transcend their politics? Eitan thought this was a question worth studying. He teamed up with Dr. Matthew Goldenberg, a psychiatrist at the Yale School of Medicine.
They were able to pull data from the Centers for Medicare and Medicaid Services, which maintains a database of U.S. physicians. — information like names, practice locations, and medical specialties.
HERSH: And I thought, of course, I should match that to the voter file so I can figure out every doctor’s politics. In most of the country, it’s a public record whether you are a registered Democrat or Republican.
Eitan is actually a bit of a specialist in public records.
HERSH: I have a set of projects where we use cool new sources of data, often public records, to study political behavior. So, whether that’s a study of the effect of 9/11 on victims’ families to obituary data on opioid victims — using interesting data from all over the place to understand people’s politics.
So, Eitan and Matt started their project by linking doctor data to voting records. They found something interesting about how a doctor’s politics relates to their specialty.
HERSH: You have the surgical specialties where nearly everyone’s Republican. And then you have the psychiatrists and the pediatricians on the other side, where everyone’s a Democrat. And you have a bunch of specialties in the middle. And primary care, of course, is one of them.
I asked Eitan whether he thought it was the specialty that influenced a doctor’s politics, or the other way around.
HERSH: I think that the partisanship is more stable. So, I don’t think that medical students are sort of a blank slate and then once they become surgeons, they make a ton of money and then become Republicans. No, no, I think it’s much more likely that the Republicans become the surgeons, and the Democrats become the psychiatrists.
Eitan and Matt aren’t the only ones to have studied the political orientation of doctors. The political scientists Adam Bonica and Howard Rosenthal, and the late medical school professor David Rothman, linked data on political contributions of more than 100,000 doctors to their specialties and they found similar results. Doctors, in general, contributed more to Republicans than Democrats, though increasingly doctors were trending away from the Republican Party. Where a doctor stood politically also tended to relate to how lucrative their specialty was. Doctors in higher-earning specialties, like surgery, were more likely to donate to Republicans.
But back to Eitan and Matt. They weren’t just interested in studying the political orientation of doctors. They wanted to understand whether a doctor’s political orientation could influence their behavior.
So, they mailed out surveys to a sample of doctors. Doctors were given a bunch of medical scenarios to consider: how doctors would counsel patients about the use of alcohol, tobacco, marijuana, and motorcycle helmets; how they would treat diseases like obesity or depression. The other scenarios asked doctors to consider the seriousness of gun storage, having sex with a sex worker, and abortion. The doctors were asked to rate how serious they considered each of these issues to be, and were given treatment options. The findings were published in 2016 in the Proceedings of the National Academy of Sciences, or P.N.A.S.
HERSH: The big question of our study was: do people’s politics affect how they treat patients?
And the answer?
HERSH: Yeah, for sure. We did the whole study kind of with this hypothesis in mind that people have all sorts of ideas in their head that affect their judgment. It’s particularly on areas of medicine where there wouldn’t be necessarily a straightforward answer.
What exactly does Eitan mean by “a straightforward answer?” Let’s think about how a doctor might approach one of these situations, like wearing a motorcycle helmet. Some conservatives might believe that people have the right to choose whether to wear a motorcycle helmet or not, rather than have to abide by a law requiring them to do so. The scenario the doctors were given about helmet use went a little bit like this: A healthy male in his 30s comes into your office for a physical. It’s his first appointment with you and he doesn’t have any known prior chronic medical issues. The patient tells you that he rides a motorcycle into work and rarely wears a helmet, but don’t worry — he’s a safe rider and hasn’t been in a major collision. How likely are you, the doctor, to consider this a serious issue?
Probably pretty serious. It’s hard to imagine a doctor telling their patient it’s okay to ride without a helmet. The survey found that Democratic and Republican doctors were equally concerned in this scenario. In other words: this wasn’t really a political issue.
The other issues that fell into this not-so-political camp were using tobacco, drinking alcohol, and treating depression and obesity. Doctors rated those with similar levels of seriousness regardless of their party affiliation. But with some of the other issues, there were clear differences. For instance, when it came to guns …
HERSH: We give a vignette about firearms, that basically there’s a parent with young kids. And they have firearms stored in their house. Are you concerned about this? And Republican physicians are way less likely to say that they’re concerned about it than Democratic ones are. But Republican physicians are also more likely to say that they would ask questions about safe storage practices. And I remember presenting this once and a physician said, “Well, you know, probably Republican physicians know more about safe storage practices.” And so, maybe that’s a good lesson.
While Democrats were more concerned about gun storage, Republicans were more likely to be concerned about abortions, and to discourage patients from having them. As for marijuana use, Democratic doctors were less concerned about their patients using the drug recreationally. Republicans, meanwhile, were more likely to talk about the health risks of marijuana, along with its legal risks. Eitan says these findings could have big implications for patients.
HERSH: You know, people have all sorts of conversations with their doctors. We don’t think there’s a lot of political evangelizing happening in the exam room. But when politically sensitive issues come up, people have their own ideological biases. And so, when you’re asked about something like marijuana or reproductive health — especially if it’s not like a straightforward, everyone-knows-the-answer-to-this question — we think there might be some ideological or partisan biases.
But how could the researchers be sure that these medical decisions were being driven by the political preferences of doctors and not the political preferences of the patients that they may treat?
HERSH: One really cool thing we could do — I mean, cool from a social science perspective, not, like, genuinely cool — is that we could study doctors who were in mixed-partisan practices. We over-sampled physicians who were in practices where some of the doctors were Republicans and some were Democrats. And we sampled doctors of both parties in the same practices, and we see the same results. So, that way we know that what’s going on here is not about patient population or where the practice is, but it’s actually something related to the doctors themselves.
“Related to the doctors themselves.” Well, what did doctors think of these findings?
HERSH: Well, I— should I tell you the story? Let me tell you the story. I can’t remember where I was giving the talk, but, I said, you know, “Oh, maybe I should just, like, make a website where everyone can look up their doctor’s party affiliation.” I was at the time on the tenure track, but not tenured. And someone said, like, “You will not get tenure.” I think that doctors really didn’t like that idea. And it’s funny because, you know, we get to look up some information about our doctors, like their gender or where they went to medical school. It’s an interesting question. Like, why would people care where their physician went to medical school? Here, we see something that seems to be correlated with how doctors are treating their patients.
Take something like reproductive health.
HERSH: I mean, if you were in a state where about half the doctors are Democrats, Republicans. Half of the O.B.s are Democrats, Republicans. A state like North Carolina is like that. Maybe you’d want to know, like, “Oh yeah, I’d prefer to go to an O.B. who’s a Democrat. Not because I care that they’re a Democrat, but because I think that they’re going to give me a different kind of care on something that’s important to me.” I’ve encountered people who say they want to go to a pro-life doctor because they don’t want to be bugged about prenatal testing, for example. And so, of course, I’m sure there are doctors listening who would be mortified by that for a business reason. Like, I don’t want to lose half my business. But I think there’s more of a reason that’s like, “Hey, I don’t think I practice medicine in a way that should be treating people differently based on who they are or who I am. And I’m just trying to do my best here.” And yeah, I think that’s a legitimate thing, but so is the fact that, as we show, when it comes to something like how they respond to a patient who regularly uses marijuana, Democrat and Republican doctors do seem to treat those patients really differently.
For the record: Eitan does not plan to build a website that details doctors’ political preferences.
HERSH: Look, I— I totally agree that it’s icky to deliberately politicize healthcare by making a website to identify every doctor’s partisanship. On the other hand, doctors, just like any other person in a decision-making job, sometimes has to come kicking and screaming into the realization of their implicit biases. Judges, police officer, anyone. What I hope this study is a good conversation starter among physicians about what they do and why they do it.
Okay, consider the conversation started. And other researchers have been joining in. The economists Elaine Hill, David Slusky, and Donna Ginther found Catholic hospitals provide different care than non-Catholic hospitals when it comes to reproductive health. They saw that when non-Catholic hospitals merge with a Catholic-owned hospital or hospital system, those hospitals reduced the number of tubal ligations — what most people call getting your tubes tied — by about 30 percent. That’s a form of contraception and with a reduction in use, we might expect more unintended pregnancies.
Now, not all studies have found that a doctor’s politics influence how they treat patients. We’re going to take a short break but when we come back, we’ll look at some of my own research that points in a pretty different direction, and we’ll see how this all plays out in the age of Covid.
* * *
A couple of years ago, I published a paper with Andrew Olenski, Dhruv Khullar, Adam Bonica, and Howard Rosenthal in the journal B.M.J. We wanted to know if a doctor’s politics made a difference in what they recommended when it came to end-of-life care.
You may remember the case of Terri Schiavo, the Florida woman who had spent 15 years brain dead after a cardiac arrest. Her story was everywhere in the media, when her husband fought to have her feeding tube removed. Even President George W. Bush stepped in, signing a law to allow a federal judge to get involved in the case. He said: “In cases like this one, where there are serious questions and substantial doubts, our society, our laws, and our courts should have a presumption in favor of life.” Eventually, the courts sided with Terri’s husband, and Terri died in 2005. This was such an intensely debated issue — particularly between Democrats and Republicans — that my colleagues and I figured end-of-life care would be a good place to look at how doctors’ political views might affect the treatments that they give.
We looked at the records of some 1.5 million Medicare patients who died in the hospital and were, by definition, at the end of life. We studied whether patients treated by Republican doctors were more likely to receive intensive end-of-life care — things like breathing tubes, dialysis, or feeding tubes. We identified Republican and Democratic doctors using publicly available political contribution data. We didn’t find any evidence that doctors’ political affiliations were linked to the intensity of end-of-life care that their patients received. This was kind of surprising since preferences for end-of-life care are often intricately linked to religious and moral concerns, which themselves often align with political beliefs. So, it was a little odd that our findings didn’t align with Eitan and Matt’s. I asked Eitan what he thinks might have been going on.
HERSH: There are moments when this was politicized, but I think that, compared to, say, firearms or abortion or marijuana, it’s less so. So, that’s one gut reaction of why there might be a difference. And of course, something like vaccines — you know, they were somewhat politicized before, but we’re at a different level, you know. Things change, right? So, I mean, today I was teaching about absentee balloting and early voting, which were things that were not politicized until this year, right? So, all of a sudden, things can become on the political agenda that aren’t before. And then that starts this process of seeping into people’s world views in an ideological way where it wasn’t so before.
Eitan’s paper is now about five years old. He thinks it’s very possible that if he repeated the surveys again, some of the doctors’ responses would be very different. For instance: even in these past few years, more states have legalized marijuana and the degree of political polarization that he observed may be less today.
So far, we’ve been talking about doctors and politics without talking about that thing that’s changed pretty much everything in our lives for the past two years. It actually kind of hurts to say two years — but it’s been two years!
BARNETT: The elephant in the room has been Covid, of course.
That’s Dr. Michael Barnett. He teaches at Harvard’s School of Public Health and is a primary care physician at Brigham and Women’s Hospital in Boston. His research focuses on the effectiveness of healthcare delivery.
BARNETT: When I was a medical student, I was just shocked by how kind of on the fly so many decisions seem to be in the hospital and that there wasn’t really a whole lot of consistency between how one person was treated or another one.
The lack of consistency in what doctors do is now widely recognized. My own work has shown that even within the same hospital and when treating similar patients, doctors vary tremendously in how much medical care they recommend to patients and how often they prescribe certain drugs. What we don’t fully understand, though, is why this variation exists in the first place. Why do doctors differ? We could literally spend hours talking about that, but I want to ask a more narrow question: why do some doctors differ when it comes to how they treat Covid-19?
BARNETT: More than any event in recent memory, it has been like an ice pick driving political division across a whole number of clinical issues.
We know that the public has been divided along political lines on things like masking, social distancing, and vaccines. But are doctors also divided?
BARNETT: There’s just very strong anti-science, anti-establishment agenda that is embraced fairly uncritically by the right, and the left is trying to battle against it. And physicians are going to also fall across that spectrum. Of course, it’s not just vaccines, right? It’s masks. We’ve never really seen political divisions on things quite as basic as this before.
Ninty-six percent of doctors are vaccinated, and most are recommending the vaccine to their patients. But Michael has been looking at whether the political beliefs of doctors affect the ways they treat Covid-19 — in particular, the use of drugs like hydroxychloroquine and ivermectin. Conservative politicians and media have touted both drugs as possible treatments. Hydroxychloroquine is a drug that’s been prescribed for decades.
BARNETT: It has two major uses. One is for prevention and treatment of malaria. it also has beneficial effects for people with autoimmune illnesses like rheumatoid arthritis or lupus.
And ivermectin is an old drug too, but has been less commonly used…
BARNETT: In primary care we use it most frequently as a treatment for scabies. And, as folks have probably heard, it’s used more extensively in veterinary medicine since animals are much more likely to get parasitic infections.
Several studies found that hydroxychloroquine wasn’t effective at treating Covid. As for ivermectin …
BARNETT: A lot of the evidence was mixed, but it’s also super low quality and not peer reviewed. And it turns out actually that in a recent analysis of a whole bunch of trials together that ivermectin does not appear to be effective. And actually, the clinical trial that initially got people most excited about ivermectin turns out to have been fabricated. The data was fraudulent.
Still, some politicians and doctors have continued to recommend the drugs.
BARNETT: It does worry me as a researcher because it’s a lot harder to address with the standard tools that policymakers reach for. You can’t just, you know, legislate on, “Hi, the doctors now can’t prescribe hydroxychloroquine.” I mean, it has to be something that’s dealt with within the profession, and that’s tough.
This brings us back to Michael’s question about how prescribing drugs like hydroxychloroquine and ivermectin may be affected by a doctor’s politics.
BARNETT: We are looking at this hypothesis: does political orientation seem to be associated with prescribing for hydroxychloroquine or ivermectin or other related Covid-19 therapies?
Michael’s work isn’t published yet so I don’t want to say too much about it, except that he finds sharp increases, in the last year, in the use of hydroxychloroquine and ivermectin in disproportionately Republican counties. Now, it’s possible that patient preferences may have driven some of that use, but I don’t think that we can chalk up the increase in prescribing of these drugs to patients’ political beliefs alone. The reason is that these medications can’t be taken without a doctor’s agreement and prescription. That means that patients can’t simply convince their doctors to prescribe these medications unless their doctors have an inclination to prescribe the drugs already. And that inclination, Michael believes, may stem from a doctor’s political ideology.
BARNETT: What we’re finding is very consistent with the kind of results you’d expect with the current polarized environment.
I want to end today’s episode with a story and reflect a little bit about the polarization that we’re seeing in the U.S. today.
On a spring day in 1981, a man named John Hinckley, Jr. was standing outside a Hilton hotel in Washington, D.C., with a group of reporters. President Ronald Reagan was inside the hotel, giving an address to a labor union. As Reagan left the building, Hinckley crouched in the crowd, and fired six shots at the president. One of the bullets hit Reagan in the chest; three other people in Reagan’s entourage were also hit.
The president’s Secret Service team shoved Reagan into the car and rushed him to the George Washington University Hospital. The bullet missed his heart, but his lung had collapsed; so, he needed immediate surgery. As doctors and nurses prepped the president for surgery, Reagan said to the surgeon, “I hope you’re a Republican.” The doctor’s response was simple: “Today, Mr. President, we’re all Republicans.”
That story resonates with me not only because of President Reagan’s wit in a clear time of distress. But also because of the doctor’s response — it’s how we would hope all doctors would act. Look, doctors are humans; we have ideologies, beliefs, preferences like everyone else. But we also take an oath to do no harm, to always act in the best interests of all patients.
And that brings us to today and the political polarization that’s happening among all of us, not just doctors.
It’s impossible not to feel that people are divided on so many issues related to Covid-19: vaccines, whether to travel, whether to wear masks. And to some extent that’s true. But what’s also true is that none of us are immune to Covid-19. And I don’t mean antibodies — lots of Americans have those now. I mean, none of us are immune to what Covid-19 has done to our lives. All of us have paid a price, one way or the other. And even among those who have chosen to not be vaccinated, to not wear masks, many have lost someone they loved. And that is the highest price one can pay.
And on that note, I want to give you a preview of next week’s episode in this two-part series on politics and medicine.
JENA: Would it be okay if I call you Dr. Senator Frist?
FRIST: Yeah, yeah. Preferably in that order, because nobody likes the politicians these days.
That’s former U.S. Senator Bill Frist. He’s a Republican who represented Tennessee from 1995 until 2007. He also happens to be a medical doctor, the first to become a senator in almost 70 years.
Next week on Freakonomics, M.D., Senator — I mean, Doctor-Senator! Bill Frist and I continue this conversation about how politics impacts medicine, and vice versa. He tells me about his unique challenges of being a trained physician in the thick of the Washington swamp.
FRIST: I had my challenge just trying to explain to 60 lawyers, you know, the intricacies of embryonic stem cell.
And we get to the heart of the matter: why there is such a divide when it comes to the politics of our bodies, and how we can bridge that gap.
That’s all coming up next week on Freakonomics, M.D. If you’d like, please send me your thoughts about this or any episode. I’m at B-A-P-U at freakonomics.com. If you’re interested in learning more about the researchers and studies I referenced today, or if you want to read a full transcript of this episode, those are all at freakonomics.com. We’ll be back next week; thanks for listening.
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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter and Instagram at @drbapupod. Original music composed by Luis Guerra. This episode was produced by Mary Diduch and mixed by Eleanor Osborne. The supervising producer was Tracey Samuelson. We had research assistance from Alina Kulman and Jacob Clemente. Our staff also includes Alison Craiglow, Greg Rippin, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jasmin Klinger, Emma Tyrrell, Lyric Bowditch, and Stephen Dubner. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.
HERSH: I have to say when this paper came out and I sometimes presented it to medical audiences, I got in a bit of trouble, um— yeah, so the social scientists liked it.
- “Flawed Ivermectin Preprint Highlights Challenges of COVID Drug Studies,” by Sara Reardon (Nature, 2021).
- “Reproductive Health Care in Catholic-Owned Hospitals,” by Elaine L Hill, David J G Slusky, and Donna K Ginther (Journal of Health Economics, 2019).
- “Physicians’ Political Preferences and the Delivery of End of Life Care in the United States: Retrospective Observational Study,” by Anupam B Jena, Andrew R Olenski, Dhruv Khullar, Adam Bonica, and Howard Rosenthal (BMJ, 2018).
- “Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use,” by Michael L. Barnett, Andrew R. Olenski, and Anupam B. Jena (The New England Journal of Medicine, 2017).
- “Variation in Physician Spending and Association With Patient Outcomes,” by Yusuke Tsugawa, Ashish K. Jha, Joseph P. Newhouse, Alan M. Zaslavsky, and Anupam B. Jena (JAMA Internal Medicine, 2017).
- “Physician Speech and Firearm Safety: Wollschlaeger v. Governor, Florida,” by Theodore T. Lee and Gregory D. Curfman (JAMA Internal Medicine, 2017).
- “Democratic and Republican Physicians Provide Different Care on Politicized Health Issues,” by Eitan D. Hersh and Matthew N. Goldenberg (PNAS, 2016).
- “Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat,” by Margot Sanger-Katz (The New York Times, 2016).
- “The Political Polarization of Physicians in the United States: An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012,” by Adam Bonica, Howard Rosenthal, and David J. Rothman (JAMA Internal Medicine, 2014).