Is there a doctor in the House? Yes, and they’re (mostly) all Republicans

In one moment, Rep. Andy Harris (R-Md.), an anesthesiologist, is holding a news conference advising people to get vaccinated. He’s even helped administer COVID-19 shots in his eastern Maryland district.

But in another moment, Harris is on the radio talking about his disappointment that he couldn’t find a pharmacy that would fill a prescription he wrote for ivermectin—an antiparasitic—to treat a patient with COVID-19, a viral infection.

The arts of medicine and politics don’t always go well together.

In an era when public health has become intensely politicized, Republican doctors in Congress walk a fine line between following the party and appealing to conservative voters while dispensing medical advice that sometimes runs counter to the mainstream.

The Food and Drug Administration has cautioned people against using ivermectin to treat or prevent COVID-19 infection because it hasn’t been approved for that purpose. The American Medical Association and other physician societies strongly oppose prescribing or dispensing the drug to COVID-19 patients outside of clinical trials. Harris later noted that physicians can and do routinely prescribe drugs off-label at their discretion.

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Harris is a co-chair of the GOP Doctors Caucus, a group of 18 House physicians, dentists and pharmacists established in 2009 while Democrats in Congress were writing the Affordable Care Act. The caucus routinely weighs in on health policy matters, such as ACA repeal, surprise billing, physician payment and the pandemic. Republican leaders frequently cite their expertise.

Harris, who was first elected in 2010, said passage of the ACA inspired most of the Republican doctors currently serving in Congress to seek office.

“Physicians in general, especially those in private practice, were getting frustrated by the amount of paperwork and the government and insurance companies both making the practice of medicine much more difficult and interfering with the normal patient-doctor relationship in many ways,” Harris said.

Physicians undoubtedly bring experience to Congress that most lawmakers don’t have. They are medical professionals who have provided patient care and have firsthand experience with the real-world consequences of federal health policy.

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However, this perspective leans heavily Republican: 20 of the 23 doctors, including all five dentists, currently serving in Congress belong to the GOP. This group also represents a narrow segment of their profession in other ways. These doctors are almost all white men from rural areas, whereas the physician workforce itself is growing increasingly urban and liberal, and women and people of color are joining the ranks in record numbers.

Physicians have served in Congress since the beginning of the republic. Even before then, several were signatories of the Declaration of Independence and the Constitution. From 1960 on, they’ve mostly been Republicans, according to a JAMA article published in 2004.

That’s still the case today, and it’s unrepresentative of physicians’ political affiliations outside Congress. In 2016, 35% of doctors considered themselves Democrats; 27% said they were Republicans and 36% identified as independents, according to a Gallup survey. But there are only three Democratic doctors currently in Congress, all in the House.

Conflicting views

Often, the GOP Doctors Caucus in the House focuses on health policy matters. But when its members espouse controversial, misleading or flat-out wrong views on health and medical issues, it detracts from that work, lobbyists say.

Congressional Democrats also are hesitant to work with some Republican physicians. Together, this limits the influence some physician lawmakers have in applying their professional experiences to policy making.

“I don’t work with all Republican physicians in Congress,” said Rep. Raul Ruiz (D-Calif.), who worked as an emergency room doctor until he was elected to Congress in 2012.

Ruiz didn’t specifically name the members with whom he won’t collaborate. But he did explain why he doesn’t think it would be worth the effort: “Some of them put partisan ideologies over pragmatic patient-centered, patient-first perspectives. I work with the physicians that also have a patient-centered focus on the issues we have common ground on.”

During the pandemic, Republican physicians in Congress have on a number of occasions floated baseless conspiracy theories, misrepresented scientific evidence and cast doubt on COVID-19 vaccination.

Rep. Randy Jackson (R-Texas), an emergency medicine doctor, recently suggested without evidence that Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, could be responsible for creating the virus. Sen. Rand Paul (R-Ky.), an ophthalmologist, has made similar accusations, among others, about Fauci. Sen. Roger Marshall (R-Kan.), an OB/GYN, has questioned the efficacy of masks. Rep. Mark Green (R-Tenn.), an emergency physician, falsely claimed in 2018 that vaccines could be linked to autism.

And while Harris and other Republican physicians have encouraged vaccinations, they oppose employer mandates and other means to nudge people to get their COVID-19 shots. In September, the caucus wrote the Centers for Disease Control and Prevention requesting the agency “acknowledge infection-acquired immunity” despite the evidence that vaccination is superior when it comes to preventing future illness.

The rhetoric fits squarely into contemporary Republican politics, but it doesn’t align with the medical profession’s consensus views on the pandemic.

“It’s really hard for medical societies when the physicians in Congress line up on a letter that is against our current recommendations,” said Mark Del Monte, executive vice president and CEO of the American Academy of Pediatrics.

‘Enormous clout’

The GOP Doctors Caucus is highly influential within the Republican conference and its members work on a number of bipartisan health policy issues, lobbyists said. Modern Healthcare granted anonymity to some lobbyists who wanted to speak candidly without jeopardizing their relationships on Capitol Hill.

“On the Republican side, I very much have always perceived the doctors caucus to have enormous clout in health policy to the point that they’ve even written bills that have made their way into law,” said a lobbyist who has represented several different parts of the industry.

For example, when Republicans controlled the House in 2015, Rep. Michael Burgess (R-Texas), an OB/GYN, and the caucus played a key role in repealing the sustainable growth rate formula and establishing a new way to pay doctors through the Medicare and CHIP Reauthorization Act.

Sen. Bill Cassidy (R-La.) was among the leaders of the GOP’s efforts to repeal and replace the ACA in 2017. Although that gambit failed, President Donald Trump borrowed some of the gastroenterologist’s ideas and attempted to implement them through regulatory means.

Doctors were also heavily involved with the surprise billing ban Congress passed last year. The final product was viewed as being friendly to providers, with several doctors serving on committees that helped draft the legislation. Physicians in Congress are currently pushing back against the Centers for Medicare and Medicaid Services, which is responsible for implementing the law, for proposing regulations they argue are too friendly to insurers.

When Republican leaders need to test the waters on a healthcare policy, their first stop is the GOP Doctors Caucus, said another lobbyist. Their strength comes from their numbers, but it’s also one of the best-organized caucuses in the House, lobbyists say. Many congressional caucuses basically exist in name only, but the GOP Doctors Caucus actually holds meetings, meets with outsiders, issues policy statements and helps pass bills.

The lobbyist who has worked for multiple industries added that Democrats don’t usually care what a member’s professional background is. Republicans put much more stock in lawmakers’ medical experience, which makes them crucial ambassadors to their conference when it comes to health policy, the lobbyist said.

Several Republican doctors serve on committees that write healthcare laws. Burgess was the chair of the House Energy and Commerce health subcommittee for several years, including when the GOP tried to repeal the ACA in 2017, for example. Three of the Senate’s four Republican doctors—Cassidy, Marshall and Paul—sit on the Senate Health, Education, Labor and Pensions Committee. GOP Sen. John Barrasso (Wyo.), an orthopedic surgeon, and Cassidy are members of the Senate Finance Committee.

Bipartisanship

While Republicans are in the minority in both houses, there’s a very real chance they could win back the majority in 2022, putting the GOP Doctors Caucus back at the forefront of healthcare policymaking.

The last time Republicans had the majority, they tried to repeal the ACA, block-grant Medicaid and restrict access to abortion. The party successfully repealed the ACA’s individual mandate penalty, sparking a lawsuit from Republican state officials that threatened to wipe out the ACA but ultimately failed at the Supreme Court.

When the caucus is successful, it’s usually on less controversial matters, like physician reimbursement.

That drives a large part of the caucus’ work, Burgess said. “Most of us who are in office now came to this place from private practice, where we ran our own practices, and were responsible for our own hiring and firing decisions,” he said.

That’s why Republican doctor-lawmakers are the first ones some lobbyists turn to when they need help on payment and practice issues. “If you were a provider who was on the front lines dealing with (administrative) burden, those who had that kind of experience are most helpful,” a provider lobbyist said.

Rep. Brad Wenstrup (R-Ohio ), a podiatrist first elected in 2012, recalls being frustrated by the yearly anxiety about the looming fee cuts from the sustainable growth rate policy.

“Congress kept telling doctors across America: Keep seeing patients, paying staff and paying bills,” Wenstrup said. “Some revenue has to come in. We had to go and get credit. I don’t know that everyone in Washington understands that.”

There is some bipartisan support on some of these smaller healthcare issues, said Rep. Ami Bera (D-Calif.), an internal medicine doctor who is teaming up with Rep. Larry Bucshon (R-Ind.), a cardiothoracic surgeon, to push for Medicare pay increases.

“If you take out their attempts to repeal the ACA, set that aside, and take some of the social issues,” Bera said, “there are more places we can work together.” Payment reform, prior authorization and workforce issues are some examples, he said.

Another area of common ground Republican and Democratic doctors in Congress cited is frustration with increasingly burdensome insurance rules.

Wenstrup and Ruiz are working on legislation to limit “step therapy,” an insurer policy that requires patients try cheaper drugs first before moving on to more expensive ones.

“Dr. Ruiz and I can very easily relate to what this does sometimes to patient care,” Wenstrup said. “You have people deciding what someone should receive as their treatment when they’ve never even seen a patient before. That doesn’t seem appropriate.”

Those bills may not advance next year, but the looming midterms and a post-election “lame duck” session could mean Congress turns to bipartisan priorities.

Specialty vs. primary care

Almost all of the Republican doctors serving in Congress are specialists, unlike the majority of U.S. doctors, who practice primary care, family medicine or pediatrics. But these lawmakers do tend to represent the political views of the majority of their fellow specialty practitioners: Surgeons, anesthesiologists, urologists and other specialists are more likely to be registered Republicans, according to a New York Times analysis from 2016.

Among other things, this means the perspective of most doctors isn’t well-represented in Congress. Rep. Kim Schrier (D-Wash.), a pediatrician, is a “one-woman show” when it comes to primary care, one lobbyist for physicians said.

“Primary-care doctors tend to be more focused on expanding coverage and promoting access to preventive care, addressing health equity and social determinants of health,” the lobbyist said. “The specialty community is, in my experience, focused on physician reimbursement issues.”

The specialty versus primary care fight has spilled out into the open over the last few years after CMS proposed a pay increase for the latter at the expense of the former. At the time, primary-care doctors hadn’t received a significant pay increase in decades, but there was very little mobilizing by members to get them one. Doctors in Congress mobilized to stop the cuts to specialists, getting leaders to pass $3 billion in temporary funding.