All-mail voting in Colorado increases turnout and reduces turnout inequality.

The COVID-19 crisis has generated interest in all-mail voting (AMV) as a potential policy solution for avoiding in-person elections. However, the quality of AMV implementation has varied greatly across states, leading to mixed results in previous research. We exploit the understudied 2014 implementation of AMV in Colorado to estimate the effect on turnout for all registered voters, along with age, racial, education, income and wealth, and occupational subgroups. Using large voter file data and a difference-in-differences design within individuals, we find a positive overall turnout effect of approximately 8 percentage points-translating into an additional 900,000 ballots being cast between 2014 and 2018. Effects are significantly larger among lower-propensity voting groups, such as young people, blue-collar workers, voters with less educational attainment, and voters of color. The results suggest that researchers and policymakers should look to Colorado's AMV approach as an effective model for boosting aggregate turnout and reducing voting disparities across subgroups.

Ideological Sorting of Physicians in Both Geography and the Workplace.

CONTEXT: The distribution of physicians across geography and employers has important implications for the delivery of medical services. This study examines how the political beliefs of physicians influence their decisions about where to live and work. METHODS: Physician relocation and employment patterns are analyzed with a panel constructed from the National Provider Identifier directory. Data on political donations are used to measure the political preferences of physicians. FINDINGS: The "ideological fit" between a physician and his or her community is a key predictor of both relocation and employment decisions. A Democratic physician in a predominantly Republican area is twice as likely to relocate as a Republican counterpart living there; the reverse is also true for Republicans living in Democratic areas. Physicians who do not share the political orientation of their colleagues are more likely to change workplaces within the same geographic area. CONCLUSIONS: Physicians are actively sorting along political lines. Younger physicians have trended sharply to the left and are increasingly drawn to urban areas with physician surpluses and away from rural areas suffering from physician shortages. The findings also help explain why physician shortages are more prevalent among left-leaning specialties such as psychiatry.

Physician activism in American politics: The opposition to the Price nomination.

Although a substantial literature considers physician advocacy fundamental to medical professionalism, only a minority of physicians actually pursue it. We analyze the characteristics of 6,402 physicians who engaged in political advocacy by signing the Clinician Action Network's 2016 petition objecting to the American Medical Association's endorsement of the nomination of Tom Price as Secretary of Health and Human Services. These physicians were matched to the NPI (all physicians) and PECOS (largely Medicare payment recipients) directories. Physicians in the directories were matched to publicly disclosed campaign contributions. Contributions are used to measure political preferences expressed on a liberal-conservative scale. We document a pronounced generational realignment in the politics of the medical profession, with recent graduates trending sharply Democratic. Petition signing vs. non-signing is responsive to gender, specialty, geographic location, personal liberal-conservative preferences and year of graduation from medical school. Petition signers were more likely to be women (62% of signers versus 34% of non-signers), recent medical school graduates (58% of signers versus 42% of non-signers), and in lower-paying specialties (27% of signers versus 12% of non-signers). The changing face of physician advocacy has important implications for understanding how the medical profession is likely to influence health care policy in coming decades.

Physicians' political preferences and the delivery of end of life care in the United States: retrospective observational study.

OBJECTIVES: To compare the delivery of end of life care given to US Medicare beneficiaries in hospital by internal medicine physicians with Republican versus Democrat political affiliations. DESIGN: Retrospective observational study. SETTING: US Medicare. PARTICIPANTS: Random sample of Medicare beneficiaries, who were admitted to hospital in 2008-12 with a general medical condition, and died in hospital or shortly thereafter. MAIN OUTCOME MEASURES: Total inpatient spending, intensive care unit use, and intensive end of life treatments (eg, mechanical ventilation and gastrostomy tube insertion) among patients dying in hospital, and hospice referral among patients discharged but at high predicted risk of 30 day mortality after discharge. Physicians were categorized as Democrat, Republican, or non-donors, using federal political contribution data. RESULTS: Among 1 480 808 patients, 93 976 (6.3%) were treated by 1523 Democratic physicians, 58 876 (4.0%) by 768 Republican physicians, and 1 327 956 (89.6%) by 23 627 non-donor physicians. Patient demographics and clinical characteristics were similar between groups. Democrat physicians were younger, more likely to be female, and more likely to have graduated from a top 20 US medical school than Republican physicians. Mean end of life spending, after adjustment for patient covariates and hospital specific fixed effects, was US$17 938 (£12 872; €14 612) among Democrat physicians (95% confidence interval $17 176 to $18 700) and $18 409 among Republican physicians ($17 362 to $19 456; adjusted Republican v Democrat difference, $472 (-$803 to $1747), P=0.47). Intensive end of life treatments for patients who died in hospital did not vary by physician political affiliation. The proportion of patients discharged from hospital to hospice did not vary with physician political affiliation. Among patients in the top 5% of predicted risk of death 30 days after hospital discharge, adjusted proportions of patients discharged to hospice were 15.8%, 15.0%, and 15.2% among Democrat, Republican, and non-donor physicians, respectively (adjusted difference in proportion between Republicans v Democrats, -0.8% (-2.7% to 0.9%), P=0.43). CONCLUSIONS: This study provided no evidence that physician political affiliation is associated with the intensity of end of life care received by patients in hospital. Other treatments for politically polarised healthcare issues should be investigated.

The political polarization of physicians in the United States: an analysis of campaign contributions to federal elections, 1991 through 2012.

IMPORTANCE: Few current data are available regarding the political behavior of American physicians as the number of female physicians has increased and the number of solo practitioners has decreased. OBJECTIVE: To analyze campaign contributions that physicians made from the 1991 to 1992 through the 2011 to 2012 election cycles to Republican and Democratic candidates in presidential and congressional races and to partisan organizations, including party committees and super political action committees (Super PACs). DESIGN, SETTING, AND PARTICIPANTS: We explored partisan differences in physician contributions by sex, for-profit vs nonprofit practice setting, and specialty using multiple regression analysis. We studied the relation between the variation in the mean annual income across specialties and the mean percentage of physicians within each specialty contributing to Republicans. MAIN OUTCOMES AND MEASURES: Differences in contributions to Republicans and Democrats, for all physicians and for subgroups. RESULTS: Between the 1991 to 1992 and the 2011 to 2012 election cycles, physician campaign contributions increased from $20 million to $189 million, and the percentage of active physicians contributing increased from 2.6% to 9.4%. Of physicians who contributed during the study period, the mean percentage contributing to Republicans was 57% for men and 31% for women. Since 1996, the percentage of physicians contributing to Republicans has decreased, to less than 50% in the 2007 to 2008 election cycle and again in the 2011 to 2012 election cycle. Contributions to Republicans in 2011 to 2012 were more prevalent among men vs women (52.3% vs 23.6%), physicians practicing in for-profit vs nonprofit organizations (53.2% vs 25.6%), and surgeons vs pediatricians (70.2% vs 22.1%). In 1991 to 1992, these contribution gaps were smaller: for sex, 54.5% vs 30.9%; for organizations, 54.2% vs 40.0%; and for specialty, 65.5% vs 32.7%. The percentage of physicians contributing to Republicans across specialties correlated 0.84 with the mean log earnings of each specialty; specialties with higher mean earnings had higher percentages of physicians contributing to Republicans. CONCLUSIONS AND RELEVANCE: Between 1991 and 2012, the political alignment of US physicians shifted from predominantly Republican toward the Democrats. The variables driving this change, including the increasing percentage of female physicians and the decreasing percentage of physicians in solo and small practices, are likely to drive further changes.