Tony Nelo
Abstract
The topic of physician attitudes towards socialized medicine has been one of the most tragically ignored conversations in American politics today. Despite the concept of socialized medicine being debated rather frequently, the ideas and concerns of those who will be providing the service are often swept under the rug, which may be due to the lack of professional research on the topic. The following study utilizes data collected by the American National Election Studies to answer the question of whether physicians have unanimous support for socialized medicine, or if the issue is as partisan as it is with the average citizen. After an independent variable t-test is conducted, the results show that physicians from the two major American political parties are more likely to side with those outside of their occupation, but within their own party. The findings of this study raise serious questions about the rational choice implications regarding the topic, as well as how socialized medicine may be viewed in the United States.
Introduction
A short conversation regarding politics with any member of society will reveal one of two things: they are either woefully uninformed or they are incredibly concerned about healthcare (though them being both is not out of the question). The concern over healthcare in the United States is nothing short of amazing, as the value of the healthcare system in America is roughly 3.4 trillion dollars, or roughly 18% of the national GDP. Whereas in European countries and even Canada, most vary between 5-12% of their nation’s GDP for their healthcare (Jones & Kantarjian, 2019). Despite the extraordinary costs of American healthcare, many in today’s society believe the American system falls short of other countries in various ways, whether that means price, cost of care, availability, etc. For three quarters of a century now, there has been intense discussion over whether or not America’s capitalist society is capable of creating a healthcare system that can serve everybody, not just those who can pay.
One solution that has been consistently suggested is the implementation of “socialized healthcare.” This phrase has also been known to cause confusion, as this concept goes by many names, with “Single-Payer” and “Medicare for All” being the most popular. The idea of socialized medicine is often pushed by American politicians that label themselves as “progressives,” which includes the likes of Vermont Senator Bernie Sanders, New York Congresswoman Alexandria Occasio-Cortez, and Massachusetts Senator Elizabeth Warren. This healthcare model is said to represent the system implemented in Scandinavian countries, such as Denmark, Sweden, and Norway where, in simplicity, the government fronts the bill for any and all healthcare costs from its citizens. As to be expected, this system has received extensive opposition from those on the other side of the political spectrum in the United States, who believe affordable and quality healthcare can be provided through the free market.
Whether or not this is what the citizens of the United States want is getting closer to being answered; the Pew Research center found that 63% of Americans believe it is the government’s responsibility to provide health coverage for all citizens (Jones, 2020). However, one subgroup of the population is often ignored in this discussion, which proves to be baffling as they are the ones who have their careers focused on the issue: physicians. The question of if physicians desire the implementation of socialized medicine has been a tragically ignored topic, as a small number of vocal doctors for both sides of the argument are often the only ones heard. Ignoring the voices of physicians on this topic is nothing short of an injustice, as they are the ones that provide care to the American people.
Within the issue of what healthcare workers want, the question is raised of whether they are any different from the average American on the matter. The healthcare discussion has become a severely political issue, with the Republican party opposing socialized medicine, while the Democrat party supports it. Knowing this, will physicians favor or oppose socialized medicine because of their occupation or is it a partisan issue like the rest of society? Will physicians align more with those in their occupation or their party? Does rational choice theory play any sort of role in physician’s approval rate on the topic? These questions are designated as the driving forces for the following research.
Literature Review
When discussing this topic, it is important to note that the United States does have socialized healthcare in their own ways. The American versions of socialized medicine appear in various programs established throughout the back half of the twentieth century. Both Medicare and Medicaid were enacted into law in 1965 by President Lyndon B. Johnson (Berkowitz, 2005). The desire for some kind of national health program really began after the conclusion of the second World War, when soldiers returning from fighting overseas were beginning to suffer from medical conditions that were acquired while deployed (Berkowitz, 2005). First came Medicare, which at the time was referred to as “Eldercare”, since the purpose was to provide people above the age of 65 with healthcare (Berkowitz, 2005). With the bill, it also included the groundwork for Medicare Parts A and B, which provide coverage for hospital visits and routine physician appointments, even though these parts were not established until later (Berkowitz, 2005). Medicaid came along with it, which provided the same benefits of Medicare, but instead to low income people under the age of 65 (Berkowitz, 2005). Before the enactment of these programs, healthcare in the United States was completely private, with insurance companies, some of which are still around today, offering healthcare to the citizens at a cost (Berkowitz, 2005).
Slightly before the enactment of Medicare and Medicaid, Congress enacted the Dependent’s Medical Care Act, which was the initial response to the desire for health coverage for those returning from war (Dolfini-Reed & Jebo, 2000). This act provided the basis for providing healthcare to active duty soldiers, their dependents, as well as military retirees and their dependents (Dolfini-Reed & Jebo, 2000). After decades of reworking what was provided in this coverage, such as including dental coverage in 1986, this program was renamed TRICARE in 1997, and still acts as the main healthcare provider for members of the military and their families (Dolfini-Reed & Jebo, 2000). In the same year that the name TRICARE came into existence, another program came about, this one focusing on the children of the United States. The Children’s Health Insurance Program (CHIP) was enacted in 1997 and was meant to extend coverage to children in families who could not afford private insurance, but also had incomes too large to qualify for Medicaid (“Program History”). This program is still in place today and collects funding from the government at the state and federal level (“Program History”).
By far, one of the most discussed aspects of American healthcare is the implementation of the Affordable Care Act (ACA). This 900-page document was signed in March of 2010 by President Barack Obama, giving the act its nickname of “Obamacare.” This piece of legislation was meant to do various things to the healthcare market (Garcia & King, 2011). One of the first actions it took was expanding coverage to even more uninsured Americans, as it extended coverage to people who had incomes 133% below the national poverty line (Garcia & King, 2011). It also prevented insurances from denying people with preexisting conditions healthcare and required insurance plans to cover the children of the policyholder (Garcia & King, 2011). The ACA did not need to be in place for long before controversy arose around it. First, Republican lawmakers did not approve of the act requiring businesses of a certain size to provide healthcare to all of the full-time employees, as they saw it as government interference within the private sector. However, the most controversial factor of the ACA was the individual mandate, which was a penalty enacted on those who did not maintain “minimum essential coverage” (Hymson, 2016). Essentially, this was a punishment on people who did not have any sort of healthcare, as it was stated in the ACA that all citizens must possess some kind of insurance. In October of 2011, the issue of whether the ACA violated the Constitution was brought to the US Supreme Court in the case National Federation of Independent Business v. Sebelius. Chief Justice John Roberts concluded in the decision that the individual mandate is not a valid exercise of Congress’ power under the Necessary and Proper Clause of the Constitution (“National Federation…”). However, instead of striking down the act, Roberts rewrote the act to make the mandate a tax instead of a penalty, making it constitutional. While the ACA is still in effect today, the individual mandate was eventually ruled unconstitutional by a federal appeals court in December of 2019 (Caffery, 2019).
Without a doubt, the United States’ healthcare system proves to be complicated. With all of the pieces that many deem to be socialist (Medicaid, the ACA, etc.), the conversation then swings to what can be done. Much of the talk today is about implementing socialized healthcare that represents the Scandinavian model by expanding the programs the United States already has. Many believe this opens a sort of “road map” to socialized medicine, with there being a few key steps along the way. First of which is to improve the Affordable Care Act, as those on the left see the benefits of it, but still will not deny the effects it has had on insurance premiums after its enactment (Jones & Kantarjian, 2019). After that, the process becomes gradually reducing the age of enrollment for Medicare until it covers everyone in the United States, as per the “Medicare for All” plan of Vermont Senator Bernie Sanders (Jones & Kantarjian, 2019). An issue with the “Medicare for All” debate is what the supporters would do about private insurance companies. Critics of the socialized healthcare plan say the plan would never succeed without getting rid of private insurance companies, some of which have been around since the early twentieth century. While this argument still lives within the Republican party, those supporting Medicare for All say there is a place for both private and public insurances within the new system (Jones & Kantarjian, 2019).
Those on the Republican side of the political spectrum believe quality healthcare can be provided by the free market, many have also acknowledged that there needs to be some kind of government assistance provided. Thus, led to the proposal of the expansion of Health Savings Accounts, otherwise known as HSAs. An HSA is a savings account that is used for medical expenses that is compiled of money that is saved before taxes are taken out (Atlas, 2018). People who have these accounts have a High Deductible Health Plan (HDHP); having a higher deductible means that person needs to pay more than average out of their own pocket for medical expenses before insurance will begin to pay for coverage (Maciejewski, 2020). The trade off with this plan being that even though insurance will not cover medical bills right away, someone has been accruing money in their HSA to cover their deductible to lead into insurance paying the bill (Maciejewski, 2020). The HSA plans have been growing in popularity over the past decade, with the number of employers offering HDHPs rose from 4% in 2005 to 28% in 2019 (Maciejewski, 2020). Despite the growing interest in these plans, the concept has come under fire by many as these plans only benefit those that are young, healthy and rarely need medical care (Atlas, 2018).
Rational Choice Theory and Previous Physician Attitudes
After discussing the complicated nature of the American healthcare system, it is important to remember the task at hand, which is the feelings of physicians towards the matter. In the United States, healthcare is an issue divided directly along party lines, but does the same hold true for physicians? The question is whether people in this profession hold the same views as the members of the party they affiliate with, or if they let rational choice theory take control. Rational choice theory is most simply defined as the behavior someone has selected that gives them the best chance to achieve their personal goals (Joseph, 2017). In a sense, this means that people are going to make decisions that serve their best interest. In this context, are physicians more likely to commit to the side that best serves their interest? Or are there factors of socialized medicine that support their occupation?
While there is no recent research conducted on this topic, a 2009 study of physicians found that 63% of those surveyed supported the implementation of a public healthcare option. This finding was monumental at the time considering President Obama was just sworn into office and the ACA was not enacted yet. Another study conducted in 2007 found that 64% of physicians in the state of Minnesota would prefer to see the implementation of single-payer healthcare (Albers et. al., 2007). The lack of available information regarding the topic stresses the importance of the research at hand even more intensely, as the issue of whether physician support has been unjustly ignored until this study.
Theory and Hypothesis
Whether physicians support the implementation of socialized healthcare will be determined by the personal decisions made that benefit them specifically, not their occupation. This determines that rational choice is more of a determinant of approval than general occupation. The reasoning behind this is the concept of “doctor burnout.” Burnout is loosely defined as unwanted stressors affecting someone’s workplace performance (Shaikh et.al., 2019). A 2019 study of internal medicine physicians found that there are high rates of burnout within this occupation, with variables ranging from married life, to number of hours worked, to days on call (Shaikh et.al., 2019). While physicians who align themselves with the Democrat party may support socialized healthcare like their fellow party members do, the high rate of burnout among physicians is the factor that prevents support for the plan to be universal within the occupation.
H1: Physician support of socialized healthcare will depend entirely on party affiliation, leading to differing results among those in the same occupation. Average physician response will align more with those of different occupations within their party, as compared to those within the same occupation, but different party.
However, there remains a possibility that there is a universal desire throughout the occupation for socialized medicine due to financial reasons. While Rational Choice Theory does encompass all desires in regard to self-interest, it does mainly focus on economic reasons. Should socialized medicine be enacted, this would lead to a larger patient pool looking for care, meaning more revenue going towards the physicians. An acceptance of the null hypothesis could be the result of the desire of physicians to increase their personal incomes through the act.
Methodology
The data being measured in this study was collected by participants from the University of Michigan and Stanford University from the American National Election Studies website (“www.electionstudies.org”) in 2018. The data was coded to only analyze responses from those who listed their occupation as “Health Diagnosing and Treating Practitioners,” which has a sample size of 133 participants. Using only the sample from this group, an independent sample t-test was conducted with party affiliation being the independent variable (measured as a 0 for a Democrat and a 1 for a Republican) and feelings towards whether the government should increase healthcare spending as the dependent variable. The dependent variable is measured as:
1 – Decrease a great deal
2 – Decrease a moderate amount
3 – Decrease a little
4 – No change
5 – Increase a little
6 – Increase a moderate amount
7 – Increase a great deal
Should one of the members of the sample support the implementation of socialized healthcare, their response would need to reach the 7 mark on this response, as implementing such a plan would require a drastic increase in government funding. The baseline significance score was set at p= 0.05.
Results
Another noticeable finding of the test is the mean score of each party’s answers on the dependent variable test. Republican physicians had a mean score of 3.63, meaning they found themselves between desiring no change in the amount of healthcare funding there is and decreasing it a little. On the other hand, Democrat physicians had a man score of 5.20, meaning they found themselves closest to the option of increasing healthcare funding a little.
The findings of this test found the difference between the response of the Republican and Democrat physicians to be significant. The significance value came out to be 0.00, which is well below the baseline of 0.05 of significance (see table 1). This means that the difference between the mean responses of physicians is different enough to be considered substantial.
| Table 1: Republican and Democrat Physicians | ||||
| N | Mean | Std. Error | Significance | |
| p = 0.00 | ||||
| Democrats | 56 | 5.20 | .203 | |
| Republicans | 35 | 3.63 | .278 | |
While the differences between the actual values found may not seem overly different, the discovered p-value for the relationship begs otherwise. With the p-value coming well beneath the threshold of 0.05, this proves the difference between the relationship of these variables is significant enough to note. With the results proving significant, the null hypothesis can be rejected with confidence, or statistical assurance that the possibility of there being no relationship cannot be true.
Observing the results from the physician test becomes even more interesting when compared to the viewpoints of non-physicians when it comes to this issue. While the comparisons of physicians in different parties proved significant, comparing physicians and non-physicians in the same party show different results. When comparing the mean response between Republican physicians and non-physicians, the p-value came in at .238, well above the benchmark of significance of 0.05 (see Table 2). This statistic shows there is no significant difference between the mean response of Republicans who are and are not physicians. As stated previously, this means that there is no difference between the responses that would be considered substantial enough to completely differentiate between Republican physicians and non-physicians.
| Table 2: Republican Physicians and Non-Physicians | ||||
| N | Mean | Std. Error | Significance | |
| p = 0.238 | ||||
| Physicians | 35 | 3.63 | .278 | |
| Non-Physicians | 1422 | 3.50 | .047 | |
The results for Democrats are even more expendable. When comparing the average response of Democrat physicians and non-physicians the p-value came out to a .749, almost three times the result of the Republican value (see Table 3). This statistic means that there is virtually no difference between the average response of physicians and non-physicians within the Democratic Party, as shown by the average responses of 5.28 and 5.20. The average response of Democratic physicians actually came 0.08 lower than the average response of a non-physician, but the statistical analysis shows the difference is almost too minimal to even notice.
| Table 3: Democrat Physicians and Non-Physicians | ||||
| N | Mean | Std. Error | Significance | |
| p = 0.749 | ||||
| Physicians | 56 | 5.20 | .203 | |
| Non-Physicians | 1607 | 5.28 | .040 | |
Analysis
The results of the samples test found strong significance between the average responses of Democrat and Republican physicians, with the Republicans sitting between not changing the amount of funding and decreasing it slightly, and the Democrats being closer to increasing it slightly. However, the average responses of physicians and non-physicians within their own party yielded no significance whatsoever. The average responses of those within the same party were too similar for the test to claim there was any important difference, showing those in the physician occupation do not differ from non-physicians on the issue.
What this means for the issue at hand is the rejection of the null hypothesis. H1 that was previously stated, which claimed the differences among physicians regarding socialized healthcare would be divided among party lines and would not hold a universal response among occupations. With the average response of a Republican physician coming in at 3.6 and the average response for a Democratic physician coming in at 5.2, there proves to be no uniformity within the occupation.
From the results, a few conclusions can be drawn. First off, whether physicians support socialized medicine or not is determined by their party, not their occupation. Should the level of support be determined by the occupation of physicians, then similar results would be expected between physicians from both parties. However, the determined support over healthcare funding is more closely related to physicians and non-physicians within the party, as represented by the large p-value. Despite physicians being the bedrock of the progressives’ proposed system, the occupation does not drive opinions.
At the same time, the Democrat physicians who support an increase in government healthcare spending hardly resemble the progressives. An implementation of Medicare for All would require a drastic increase in government funding, with some pricing estimates of the program coming in at roughly 32 trillion dollars. To say the Democratic physicians desire an implementation of socialized healthcare would lead to the assumption of an average response of closer to 7, or “increase drastically.” While there were no costs set to each response, there is no data presented to assume physicians from either party support the level of funding required for Medicare for All. Democratic physicians may have been suspected to support the desires of the progressives, but do not appear to possess the same mindset regarding the issue.
At the same time, those within the Republican party appear to have their own distinct views of healthcare funding. The test shows the mean answer of Republicans to be in between decreasing healthcare funding slightly, and not changing it at all. With the many issues Republicans have with government sponsored health programs, the opinions of many on that side of the political spectrum appear to point towards drastic reduction in funding. However, the test shows that Republicans would rather see a slight reduction or no change to funding, which differs from the more vocal beliefs on their side of drastic reduction.
All in all, what the results show is that the average member of the two popular parties do not align with the more extreme members seen today. With respect to the question at hand, physicians are included in the average member category despite their occupation and crucial role in one of the most discussed acts. Physicians who identify with the Democrat party answered more 7’s than their Republican counterparts, meaning they support greatly increasing government spending on healthcare. However, the number of 7 responses put them above the Republicans, but not on par with the vocal progressives of today, as the number may not be substantial enough. As discussed earlier, doctor burnout plays a large role in physician actions towards their careers. Enabling large numbers of citizens to schedule appointments with physicians would increase the workload of the professionals even more than it already is. While it is reasonable to expect this would also come with salary increases in some respects, the physicians may also fear the price of socialized medicine would come at the cost of their income tax bracket.
The results of the tests also reveal a different aspect of Rational Choice Theory. While the theory mainly relates to someone making decisions in their own economic interest, the discussion of doctor burnout shows the theory can relate to other aspects of life. Rational Choice Theory does not have to simply relate to someone’s economic well being, but just overall betterment of their lives. There is a possibility socialized healthcare increases the salary of physicians by increasing the market, but selecting this option may not be in their best interest due to the workload. So while the rational decision being made is not necessarily financial, it does show that people will make decisions that lead to overall contentment with their lives, which is supported by the data above. At the same time, the data above also supports the idea that party identification is more important to decision making than occupation. Where the two ideas may connect is whether rational choice is utilized to support one’s well-being within their party, or their personal lives in general.
Conclusion
Overall, the results of this study reveal much about the political realm within the United States today. While the healthcare conversation today has shifted entirely towards socialized healthcare, almost no one has made it a concern to include the physicians. The absence of these professionals from this discussion could be the result of various reasons, which may include negligence of the specific occupation or some intentional misdirection from the crowd. While there may never be a pure answer to that question, the responses of those within the target occupation show important factors about the power of party identification. Despite being the workers who would see the biggest shift within drastically increased healthcare funding, the Democrat physicians surveyed had nearly identical responses to those within their party. Acknowledging the connection between how people think and what party they align themselves with is not a factor that can be swept to the side when studying policy, as the results here show.
What this means for the current state of this discussion is entirely subjective. Those who oppose socialized medicine may see these results as the direct answer of physicians not wanting the system, while others may see it as the issue of people in the healthcare field being unsure about what they want from the government. Those who support socialized medicine may see this as a glaring lack of progressives within the healthcare field, or at least the result of the lack of information reaching those within the field about the system. Regardless, the importance of the conversation at hand is who is included, as society must gauge whose voice makes more of a difference; the citizens receiving the healthcare or those being told to provide it.
References
Albers, J. M., Lathrop, B. P., Allison, K. C., Oberg, C. N., & Hart, J. F. (2007, February). Single-Payer, Health Savings Accounts, or Managed Care? Retrieved December, 2020, from http://www.pnhp.org/news/2007/february/singlepayer_health.php
Berkowitz, E. (2005). Medicare and Medicaid: The Past as Prologue. Health Care Finance Review, 27(2).
Blakemore, E. (2019, March 30). Democratic and Republican doctors treat patients differently. Retrieved December 05, 2020, from https://www.washingtonpost.com/news/to-your-health/wp/2016/10/03/want-to-know-how-your-physician-will-treat-you-ask-if-they-vote-democrat-or-republican/
Caffery, M. (2019, December 18). Federal Appeals Court Strikes Down ACA Individual Mandate. Retrieved December 05, 2020, from https://www.ajmc.com/view/federal-appeals-court-strikes-down-aca-individual-mandate
DiJulio, B., Kirzinger, A., Hamel, L., Wu, B., & Brodie, M. (2018, April 11). Kaiser Health Tracking Poll – September 2017: What’s Next for Health Care? Retrieved Fall, from https://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-september-2017-whats-next-for-health-care/
Garcia, A., & King, M. (2011, March). The Affordable Care Act: A Brief Summary. Retrieved December 05, 2020, from https://www.ncsl.org/research/health/the-affordable-care-act-brief-summary.aspx
Hymson, E. B. (2016). A CRITICAL EXAMINATION OF THE INDIVIDUAL MANDATE AND BUSINESS MANDATE PROVISIONS OF THE AFFORDABLE CARE ACT. Southern Law Journal, 26(1), 79.
Jebo, J., & Dolfini-Reed, M. (2000). The Evolution of the Military Health Care System: Changes in Public Law and DOD Regulations (United States, Navy, Center for Naval Analyses). Alexandria, VA: The CNA Corporation.
Jones, B. (2020, September 30). Increasing share of Americans favor a single government program to provide health care coverage. Retrieved December, from https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/
Jones, G., & Kantarjian, H. (2019). The many roads to universal health care in the USA. The Lancet Oncology, 20(10). doi:10.1016/s1470-2045(19)30517-0
Joseph, P. (2017). The Sage encyclopedia of war: Social science perspectives. Thousand Oaks,, CA: SAGE Publications.
Keyhani, S., & Federman, A. (2009). Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion. New England Journal of Medicine, 361(14). doi:10.1056/nejmp0908239
Khan, S., Spooner, J., & Spotts, H. (2018). United States Physician Preferences Regarding Healthcare Financing Options: A Multistate Survey. Pharmacy, 6(4), 131. doi:10.3390/pharmacy6040131
Maciejewski, M. (2020). High-Deductible Health Plans and Health Savings Accounts. JAMA Open Network, 3(7), E2011000. doi:10.1001/jamanetworkopen.2020.11000
National Federation of Independent Business v. Sebelius, Secretary of Health and Human Services, SupremeCourt.gov (October, 2011).
Program History. (n.d.). Retrieved December 05, 2020, from https://www.medicaid.gov/about-us/program-history/index.html
Shaikh, A. A., Shaikh, A., Kumar, R., & Tahir, A. (2019). Assessment of Burnout and its Factors Among Doctors Using the Abbreviated Maslach Burnout Inventory. Cureus, 11(2). doi:10.7759/cureus.4101