Is There a Doctor in the House? . . . Or the Senate?Physicians in US Congress, 1960-2004

Context The legislative and fiscal influences of Congress, as well as the continuing overall growth in health care spending as a portion of the gross domestic product, make congressional representation by physicians important because physicians have unique expertise in the impact of legislation on patient care and medical practice.

Objectives To describe physician representation in the US Congress between 1960 and 2004 and relate the results to past representation of physicians in Congress.

Design and Setting A retrospective observational study of members of the US Congress from all 50 states and all represented territories, who served from January 1960 to April 2004 (including 108th Congress), using data available in public access databases and congressional biographical records.

Main Outcome Measures Physician representation in Congress, including occupation before taking office, state/territory of representation, sex, party affiliation, and time served.

Results During the past 44 years, 25 (1.1%) of 2196 members of Congress were physicians. Physicians in Congress were more likely to be members of the Republican Party (60% vs 45.1% of all members, P = .007) and were similar to other members of Congress in mean years of service (9.2 years for physicians vs 12.3 years for all members, P = .09) and in sex distribution (4.0% female physicians vs 6.8% all female members, P = .57). Physicians in Congress represented 17 states, the Virgin Islands, and Puerto Rico.

Conclusions Physician representation in Congress is low and is in stark contrast with physician roles during the first century of the United States. However, the 8 physicians currently serving in Congress may be indicative of a shift toward more direct influence of physicians in national politics.

During the past 44 years, since the inception of both the Medicare and Medicaid programs, health care expenditures have become an increasing portion of the US gross domestic product (GDP) and a growing focus of concern for an aging population.^1,2 Despite these trends, physicians have assumed very few national legislative roles, a sharp contrast with the first 100 years of the United States.

The current need for physician leadership in shaping health care is especially important. The growing elderly and minority populations have necessitated a reevaluation of health care delivery and access for the entire nation. Medical liability issues have caused many states to declare a crisis in their ability to ensure quality care, and consequently, a nationwide call for congressional-mediated tort reform has come from physicians and professional organizations.³ Even on the frontiers of scientific discovery, medicine and health care are on a collision course with public policy decisions that, at times, excite emotion and debate on the floors of the House of Representatives and the Senate. Issues such as stem cell research and funding for agencies such as the National Institutes of Health are at the top of the congressional agenda.^4-8 As such, the legislative role of Congress has expanded from its more traditional responsibility of appropriating federal funds for health care to its current role of engaging in the national discourse and creating the financial and legal framework for research priorities and for the delivery of health care.

These issues combined with the steady overall growth of health care spending as a portion of the GDP during the past several decades place Congress at the crux of health care policy in the United States. Despite a slower rate of growth in 2002, spending on health care in the United States continues to grow at nearly twice that of the rest of the economy⁹ and far exceeds health care spending in all other developed nations.¹⁰ Health care spending consumes more than 14% of the GDP and is projected to increase to approximately 18% of the GDP by 2013.¹¹

Despite the increasing role of health care in the overall economy and the escalating complexity of scientific issues debated in Congress, physician participation as elected members has been limited. Instead, the function of physicians in the political arena has been focused on the lobbying efforts of individual physicians,¹² “white coat marches” by groups of physicians calling for malpractice reform,¹³ and the collective and powerful lobbying activities of professional organizations, such as the American Medical Association.¹⁴

The goal of our study is to describe the level of physician participation in the US Congress during the decades from 1960 to 2004, including the 108th Congress. This period was selected because it closely parallels the enactment of Medicare and Medicaid legislation and marks an era of active participation in health care payment and policy development on the part of the federal government. To our knowledge, no other study has examined primary congressional biographical data to assess physician representation in Congress and to describe the characteristics of those physicians.

We examined biographical records of congressional members who served at any time between January 1960 and April 2004, using the congressional biographical records.¹⁵ Data extracted included years served, party affiliation, sex, state represented, and occupation of the member before taking office. For the purposes of comparison and data analysis, we created 14 general occupational categories for congressional members: attorney, education, health care (nonphysician), military, media/entertainment, agriculture, business, banking and insurance, public service, law enforcement, clergy, physician, miscellaneous, and unknown. A physician was defined as anyone with an MD or DO degree. When available, the investigators also consulted additional biographical sources on individual physicians serving in Congress. Institutional review board approval was not sought because the data were collected using publicly available data sources of the US Congress.

To ensure accuracy of the data, 3 individuals (2 authors plus 1 paid auditor) independently examined the congressional biographical records. For those cases in which the analyses did not agree, the investigators reviewed the original data and a made a consensus decision regarding the information. Data were analyzed using SPSS version 11.0 (SPSS Inc, Chicago, Ill); P<.05 was considered statistically significant.

A total of 2196 congressional records were reviewed from January 1960 through April 2004, including the 108th Congress. Table 1 summarizes congressional representation by occupational category with mean years of service. Attorneys were the largest occupational group in Congress with 979 members (44.6%). Individuals involved in business (13.6%), public service (9.9%), and education (7.4%), respectively, were the next largest groups. Only 25 physicians (1.1%) were identified. Overall, congressional members served for a mean 12.3 years (95% confidence interval [CI], 11.9-12.7). Of all congressional representatives, 1181 (53.8%) were members of the Democratic Party, 991 (45.1%) were members of the Republican Party, 24 (1.1%) were members of other political parties, and 149 (6.8%) were women.

Table 2 shows the characteristics of physicians in Congress from 1960 to 2004. Physicians served in Congress for a mean 9.2 years (95% CI, 6.2-12.3), with no statistical difference (P = .09) between physicians and other members of Congress in mean years of service. The number of physicians in Congress at the beginning of each decade were 5 (1960), 3 (1970), 4 (1980), 2 (1990), 10 (2000), and 8 are currently serving. Fifteen physicians (60%) were members of the Republican Party, 9 were members of the Democratic Party (36%), and 1 (4%) was a member of the Popular Democratic Party of Puerto Rico. Physicians were more likely to be Republicans (60% vs 45.1%; χ²₂=14.5; P = .007) than were members of the entire study sample. Of the 25 physicians, 1 was a woman (4%) and there was no statistically significant difference in sex between nonphysician and physician members of Congress (6.8% vs 4.0%; χ²₁=0.3; P = .57).

Additionally, 23 physicians (92%) served in the House of Representatives and 2 (8%) served in the Senate. None served in both Houses of Congress. Twenty-two physicians (88%) were floor voting members, 2 (8%) were delegates (Virgin Islands), and 1 (4%) was a resident commissioner (Puerto Rico). Physicians represented 17 states and territories, with Pennsylvania and Georgia having 3 representatives each, and Arkansas, Kentucky, Texas, and the Virgin Islands having 2 each.

All physicians were graduates of allopathic medical schools. Information on practice specialty was available for 12 physicians (48%): 3 (25%) were surgeons, 3 (25%) practiced obstetrics/gynecology, 1 (8.3%) had a combined practice of medicine and surgery, 1 (8.3%) combined family practice and obstetrics, 1 (8.3%) psychiatry, 1 (8.3%) urology, 1 (8.3%) family practice, and 1 (8.3%) internal medicine. Seventeen physicians (68%) had other professional careers before entering Congress, including 11 (64.7%) with service in the military, 2 (11.8%) attorneys, 1 (5.9%) with a career both in the military and education, 1 (5.9%) territorial governor (Virgin Islands), 1 (5.9%) in agriculture, and 1 (5.9%) journalist. Eight (32%) of the physicians are currently members of the 108th Congress, and of these, 6 have previous political experience, including 4 who served as state senators.

The lack of physicians in Congress between 1960 and 2004 is in sharp contrast with the first 100 years of the United States. In 1776, 10.7% of the signers of the Declaration of Independence were physicians¹⁶ and 2 (5.1%) of the 39 crafters of the US Constitution were physicians.¹⁷ Physician participation in the first century of Congress (1789-1889) was also greater than it is today. During that time (1st through 50th Congresses), 252 (4.6%) of 5405 members were physicians.¹⁷ As the political salience and economic impact of health care in the United States have increased, physicians have taken a smaller role as congressional members.

Physician representation is especially important in Congress, because funding for research and patient care as well as insurance coverage for tens of millions of US individuals enrolled in the Medicare and Medicaid programs is dependent on Constitutional authority. As the nation’s uninsured and elderly populations increase, the costs of health care will continue to increase and will likely animate congressional debates about affordability and payment. The recent debates over Medicare reform and the prescription drug benefit highlight the need for physician leadership in discussions related to federal funding for health care.¹⁸

There are a number of possible explanations why, in comparison with their colleagues in other professions, few physicians enter public service as congressional members. The first may be that there are fewer physicians than members of other professional occupations with higher representation in Congress. However, there were 836 156 physicians working in the United States in 2001.¹⁹ Conversely, there were approximately 1 058 662 attorneys in the United States in 2003.²⁰ This 5 to 4 ratio of attorneys to physicians is not close to the 40 to 1 ratio in Congress.

Financial concerns may also influence the number of physicians in Congress. However, the mean income for US physicians is comparable with that of congressional salaries. According to the 2003 US Department of Labor/Bureau of Labor Statistics, the mean income for general internists is $160 130, for family practitioners $139 640, for surgeons $190 280, and for pediatricians $143 300.²¹ These salaries are comparable with the mean income of $154 700 earned by the members of the House and Senate.²² Based on the lack of financial incentives to seek public office, some physicians may conclude that an essentially lateral financial move is not worth the professional risk and financial burdens associated with seeking an electoral victory. Additionally, for those specialties in which remuneration is quite high, adjusting to a lower salary may be seen as too much of a financial sacrifice.

Physicians may feel that the demands of daily medical practice preclude them from exploring other career options while still devoting the necessary time and energy to quality care for patients. Another possible explanation may be the general decrease in professional morale among physicians,²³ precipitated by an increased workload, changes in practice driven by managed care and biotechnology, lower reimbursements, and increasing expectations from health care consumers.²⁴ This dynamic of contemporary health care delivery and practice may be a deterrent not only to the practice of medicine²⁵ but may discourage physicians from feeling a professional obligation for civic participation as elected officials. Additionally, medical school and postgraduate training for US physicians is highly focused and patient-centered, whereas public service as an elected official is intrinsically population-based. The educational process for those individuals in business or law is generally broader and thus may be more encouraging of a wider range of career choices, such as political office.

Finally, physicians do not have a tradition of seeking elected office. In other professions, most notably law, there are many role models with proven records of congressional service. Of the 8 physicians currently in Congress, 6 have previous political experience, 4 of whom were state senators. Our results suggest that such a tradition may not be necessary to retain physician congressional members, because physicians who serve in Congress have similar characteristics in terms of years of service and sex compared with their colleagues who enter Congress from other occupations. Governmental participation by physicians has traditionally been in other areas, such as the Centers for Disease Control and Prevention, the US military, the Department of Veterans Affairs, and the Centers for Medicare & Medicaid Services.

A greater presence of physicians in Congress—with their specialized training and unique perspectives on health care—could potentially have a significant impact on health policy, especially if physicians reach positions of congressional leadership. Leadership positions are especially important given that under congressional rules, committee and other leaders, such as the Speaker of the House and the Senate Majority Leader, play a significant role in determining the legislative agenda that reaches floor debate and voting.

Further research is necessary to explore the specific legislative activities of individual physicians in Congress. This research should include a policy analysis of health care–related issues based on sponsored legislation, commentary, and voting records. However, analysis of voting records and speeches is, by its very nature, highly subjective. Often, health care legislation is attached to larger bills that address broad budgetary issues. A congressional member’s vote on a particular bill may be influenced by many competing interests. Voting records on specific issues, such as Medicare funding or the importation of prescription medications, could be viewed as having either a prohealth or anti–health care impact, depending on an individual’s political persuasion. An assumption of our research is that physicians who are members of Congress are in a unique position to influence policy and their medical training allows them to bring an expert perspective to many issues. Additionally, we assume that, because of this training and expertise, it is important for physicians to be directly involved as lawmakers in the debates that shape these health-related issues, rather than merely reacting to the resulting legislative outcomes.

Despite a considerable decline in the public’s confidence in the institutional leadership of medicine, US individuals still hold a high level of regard and respect for the nation’s physicians.²⁶ Given the growing political polarization and partisanship in the United States,²⁷ this public esteem may provide the opportunity for physicians to become the next generation of congressional leaders.

Corresponding Author: Thomas A. Suarez, MD, Department of Anesthesiology, Division of Cardiac Anesthesiology, Sinai Hospital, The Johns Hopkins University, 2401 W Belvedere Ave, Baltimore, MD 21215 (tom_suarez_cabot_md@post.harvard.edu).

Author Contributions: Mr Kraus and Dr Suarez had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, statistical analysis, and study supervision: Kraus, Suarez.

Acquisition of data: Suarez.

Administrative, technical, or material support: Kraus.

Funding/Support: This work received no funding and the authors report no conflicts of interest.

Acknowledgment: We thank Jurek G. Grabowski, MPH, for his statistical assistance and insightful comments.