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
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
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
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
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:
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.
Chernew ME, Hirth RA, Cutler DM. Increased spending on health care: how much can the United States afford? Health Aff (Millwood)
. 2003;22:15-2512889745Google ScholarCrossref
Weiss R. Critics of NIH studies prompt Senate hearing: director also to address
work with drug firms. Washington Post. January 19, 2004:A19
Sandel MJ. Embryo ethics: the moral logic of stem-cell research. N Engl J Med
. 2004;351:207-20915254277Google ScholarCrossref
McHugh PR. Zygote and “clonate”: the ethical use of embryonic stem
cells. N Engl J Med
. 2004;351:209-21115254278Google ScholarCrossref
Stolberg SG, Broder JM. Limits on stem-cell research re-emerge as a political issue. New York Times. May 6, 2004:A1
Stone A, Vergano D. Congress looks again at stem-cell research. USA Today. June 9, 2004:5A
Strunk BC, Ginsburg PB. Tracking health care costs: trends slow in first half of 2003: center
for studying health system change. Available at: http://www.hschange.com/CONTENT/633/. Accessed
September 29, 2004
Reinhardt UE, Hussey PE, Anderson GFUS. Health care spending in an international context. Health Aff (Millwood)
. 2004;23:10-2515160799Google ScholarCrossref
Landers SH, Sehgal AR. How do physicians lobby their members of Congress? Arch Intern Med
. 2000;160:3248-325111088085Google ScholarCrossref
Jenkins CL, Becker J. Viriginia doctors march for malpractice reforms; bills would limit
awards, lawyers’ fees. Washington Post. February 5, 2004:B04
Gifford GE, . Physician Signers of the Declaration of Independence. New York, NY: Science History Publications; 1976
Iglehart JK. The new Medicare prescription-drug benefit: a pure power play. N Engl J Med
. 2004;350:826-83314973209Google ScholarCrossref
US Department of Labor, Bureau of Labor Statistics. May 2003 national occupational employment and wage estimates: health
care practitioners and technical occupations. Available at: http://www.bls.gov/oes/2003/may/oes_29HE.htm.
Accessed September 29, 2004
Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ
. 2002;324:835-83811934779Google ScholarCrossref
Kereiakes DJ, Willerson JT. Health care on trial: America’s medical malpractice crisis. Circulation
. 2004;109:2939-294115210609Google ScholarCrossref
Blendon RJ, Benson JM. Americans’ views on health policy: a fifty-year historical perspective. Health Aff (Millwood)
. 2001;20:33-4611260957Google ScholarCrossref