GOP No More: Why American Doctors Now Support the Democrats. NewsWire

NEWSWIRE: 11/11/19

• Once staunch GOP supporters, doctors are now more likely to be Democrats. The ratio of campaign contributions given by doctors to Republicans vs. Democrats has flipped since 1990—a reflection of major social and economic shifts, as well as recent politics, that are increasingly driving doctors and other white-collar Americans leftward. (The Wall Street Journal)
• NH: This is a historic shift. For well over a century--since the late nineteenth century--the growing cadre of American physicians who organized and regulated themselves as elite "Medicinae Doctori" (MDs) overwhelmingly identified with the Republican Party. Most of them were educated small-town professionals and earnest WASPs in an era when such folk just about automatically belonged to the party of Abraham Lincoln.
• In the early 1900s, their main political challenge was organizational: how to obtain exclusive legitimacy to practice and regulate all the other quacks and riffraff off the street. In this task, they received help from "progressive" Republicans. Later on, during the New Deal and postwar era, they faced a new challenge: how to prevent left-leaning liberals from taxing away their income and wealth or from "socializing" their practices in some national plan. These threats kept them firmly in the Republican camp well into the 1970s, '80s, and '90s.
• So what's changing? In an upcoming election in which at least two major candidates are proposing a single-payer national health plan, why aren't doctors rallying once again to the GOP? (See the first chart below.)
• The most obvious and recent reason has been the impact of Donald Trump on the GOP, which accelerated a trend that began about a decade ago. This is the influx of less-educated blue-collar workers to the party and the outflow of more-educated white-collar professionals from the party. (That continuing outflow was a major storyline in the last week's elections in Virginia, Kentucky, and Mississippi.) Doctors are part of this trend. Highly educated and credentialed professionals are turned off by Trump's shoot-from-the-hip style. What's more, if they're well-off, they increasingly find that their well-off neighbors are voting against the GOP as well. The richest 15% of congressional districts are now represented by 56 Democrats and only 10 Republicans. (See "Two Parties Representing Two Different Economies.")
• There's also gender. Over the last decade, the share of doctors who are women has grown from 31% to 38%. Women today vote more for Democrats than men, and that gap has recently widened. (See the second chart below.)
• And then there's generational replacement. Millennials and late-wave Xers are a lot more likely to vote against the GOP, and they are expanding as a share of all doctors. What's more, these younger doctors are a lot more likely to be female. Over the age of 65, fewer than 20% of doctors are women; under age 40, over 40% are. All of these doctors work with an expanding workforce of less-paid health-care providers who are even more likely to be Millennial and female and to vote Democratic. (See the third chart below.)
• Boosting this generational shift is a structural transformation of the economics of health care. The industry is rapidly concentrating. Independent doctor practices are getting gobbled up by large providers. And a rising share of newly minted Millennial doctors don't even consider going into business for themselves, mostly because they shun the workaholic individualism of the older generation. They would rather become salaried members of a team. (See "Goodbye, Dr. Welby.") This takes away one big reason why most doctors once saw themselves as Republicans--because they managed practices that were small businesses. Increasingly, doctors don't. (See the fourth chart below.)
• The WSJ reporters touch on most of these drivers. One shift they leave entirely unmentioned, however, is the profession's changing perception of government. Back in the mid-1960s, when LBJ first proposed Medicare and Medicaid, the AMA saw this as an attempt to take away or "ration away" doctors' income. So the doctors initially refused to give their support. But the Democrats eventually won them over by promising them a cost-plus reimbursement arrangement--whatever you normally bill, the federal government will cover. Plenty of cost-control regulations did follow, and doctors do complain about them. But the deal they made with government unquestionably worked out hugely in their favor. Total healthcare spending, only 5% of GDP in 1960, is now 18% of GDP--and just about two-thirds of that spending now comes from straight from government. And still, by and large, doctors get to determine what's appropriate for each patient.
• What's not to like in that outcome? More to the point, how could the emergence of public financing as a cornerstone of their business not affect their political sympathies? To support the party of small government would be to shoot themselves in the foot. The same could be said, btw, about the concentration of practices into a few gigantic providers in each region. Sure, it dooms the solo practitioner. But it enables monopoly pricing (now being actively investigated by the FTC) and once again boosts total healthcare revenue.
• To be sure, there remain fascinating differences in party affiliation by specialty: Higher-paid, procedure-oriented specialties like radiologists lean more Republican; lower-paid, people-oriented specialties like psychiatrists lean more Democratic. (See the fifth chart below.)
• Still, overall, most of the medical profession is now very comfortable with the Democratic Party. Democrats support the ample scale of government needed to pay their bills. And Democrats favor a therapeutic "caring" vocabulary that tends to legitimize further ills and further treatments--more so, at least, than the GOP. 
• If doctors have any qualms about the Democrats, they come from crusaders on the left who want to go too far. Single payer? Medicare for all? That sort of radicalism could eventually lead (inevitably lead, IMO) to top-down cost-effectiveness reforms. Such reforms, whether done well or done badly, would kill their golden goose. And that would be a future worse than anything the GOP has in mind. (The AMA this year maintained its opposition to single payer.) America's bloated, inefficient, and overspecialized healthcare industry--top-heavy with administrative costs and swamped by rampant overtreatment--may not be perfect. But for the time being it serves doctors' collective interests very well.

• On average, U.S. teens in 2019 spend more than seven hours a day in front of screens—not including schoolwork. The latest “media census” from Common Sense finds that screen time among teens and tweens has grown steadily since 2015, with large increases in the time spent watching online videos more than making up for a drop in time spent watching TV on a TV set. (Common Sense)
• NH: This report has been long awaited. While we have lots of updated data on digital use among adults, data on kids' use is difficult to obtain. Common Sense issued its last major report on kids in 2015.
• What are the highlights? Well, the biggest news is that the average daily time spent by tweens (age 8-12) on all forms of media has remained unchanged since 2015, at just under 6 hours. And the average daily time spent by teens (age 13-18) has increased significantly since 2015, from 8:56 to 9:49. The figures count all forms of media, including books and music, but they do not include school work.
• Six hours and close to ten hours may sound like the zombification of youth. But keep these numbers in perspective: According to Nielsen, all U.S. adults spent 11:27 daily plugged into media in Q1 of 2019. Kids are mostly just following their parents' example. Keep in mind too that these figures overestimate actual time because they inevitably double-count simultaneous consumption of more than one media source (surfing the Internet while listening to the radio, for example). Total screen media time is lower--4:44 daily for tweens and 7:22 daily for teens.
• Other trends. Time spent watching online videos has roughly doubled, from 30 minutes to an hour in both age groups. Time spent watching TV shows on linear (or "live") TV has dropped, from one half to one quarter of all TV watching. Smartphone use has become nearly universal by age 18: 91% in 2019 versus 77% in 2015. As digital access becomes universal, meanwhile, the digital divide between high- and low-income families is narrowing.
• Both in 2019 as in 2015, the authors notice some large and (maybe) predictable differences in media use by boys and girls. Boys spend a lot more time on gaming and a bit more time on videos. Girls spend more time on everything else--social media, music, reading, and TV. A third of all teens say they read for pleasure less than once a month or never.
• Contrary to general opinion, the vast majority of tweens and teens do not routinely use their devices to create their own digital content. Only one in ten say they enjoy "a lot" making digital art or graphics. And only one in twenty say the same about creating digital music or coding or modifying video games. So let's keep the post-Millennial TikTok revolution in perspective: It may not be as widespread as many imagine.

                             

• A new study is the first to show a link between higher screen time and diminished brain development in preschool children. MRI scans revealed that kids who are in front of screens more have less “white matter integrity,” particularly in areas related to language skills and literacy. (JAMA Pediatrics)
• NH: "White matter integrity" refers to the prevalence of myelin along the brain's neurons. Babies are born with very little myelin. In the first few years of life, young brains produce lots of myelin ("myelinogenesis") in response to their practice of motor, sensory, and cognitive skills. The myelin serves to improve the transmission of signals along neuronal pathways to and from different areas of the brain--the comprehension of words and the production of speech, for example. Diseases that de-myelinate neurons, like MS, can be debilitating.
• So the association found in brain scans between less myelination and more screen time in young children is potentially a big deal. Some pediatric experts are already alarmed. It comes on top of another recent study showing that excessive screen time is associated with a thinning of the cerebral cortex of small children. (See "Is Excessive Screen Time Changing Children's Brains?") It will certainly feed the "tech-lash" already challenging many of Silicon-Valley giants like Google and Facebook. ("Tech-Lash Batters Silicon Valley.")
• All that said, the key word here is "potentially." We still don't know whether the clinically measured difference in myelination has real-world significance. More importantly, as the old adage goes, correlation is not causation. It may well be that children naturally predisposed to have less verbal myelination are more attracted to digital screens. We know, for example, that identical twins raised separately from birth have a surprisingly high correlation in the daily time they watch TV, read books, or (even) have books read to them by their parents. (For more on such findings, see Robert Plomin's Blueprint.)
• Pediatricians have long argued that young children are primarily kinesthetic learners: They learn through touching, doing, and hands-on experiences. (See "No Touching! (Except If It's an iPad.)") At this age, lots of digital media is developmentally inappropriate. That commonsense argument still stands.
• Over the past decade, homelessness has declined nationally but has surged in America’s biggest cities, such as New York and Los Angeles. Research suggests that this phenomenon hasn’t been driven primarily by personal issues like drug abuse, but by unaffordable housing costs. (The Economist)
• NH: For the last ten years, on a single night in January, HUD runs its official yearly count of the number of homeless persons in the United States. That count shows a mildly declining trend--from 647,000 in 2009 to 553,000 in 2018. Contrary to the stereotype, most of these people are only temporarily homeless and most find shelter in housing provided by local governments or charities. The number of unsheltered homeless is smaller and is also declining--from 256,000 in 2007 to 194,000 in 2018. These are people sleeping on streets or in vehicles or parks, that is, in places "not designated for, or ordinarily used as, a regular sleeping accommodation."
• The unsheltered number may be declining. But still, that's a lot of people, a population roughly the size of Salt Lake City.
• One major trend, well covered in the Economist, is that while the number nationally is declining, the number in major cities is rising. In addition, the share of unsheltered homeless is highest and rising fastest in major west-coast cities. California alone is home to 85,000 of the unsheltered homeless, nearly half of the national total. And roughly half of these live in the Los Angeles area. Washington, Oregon, Hawaii, Nevada, and Texas are also seeing sizable increases in big cities.
• Why? Good weather explains something. (These HUD counts are made in January!) Many west-coast cities provide assistance to those living on the streets (which may attract new homeless) without however providing shelter or life-changing assistance that would get them off the streets. These cities also have skyrocketing housing costs, which generate homelessness by making it difficult for low-wage earners to afford to pay for their own housing. This matters for the 30% to 40% of homeless--the share on the west coast is rising--who are not disabled, not addicts, and not mentally ill.
• One trend not discussed by the author is the generational dynamics of homelessness. Though the ranks of the homeless have recently been swelled by some Millennials unable to afford to rent a room, the median age of the homeless--especially the dysfunctional homeless--continues to rise as their late-Boom and early Xer center of gravity continues to get older. (See "The Boomer Boom in Homelessness.") Eventually these aging Aquarians will put a severe strain on healthcare and social-service spending by state and local governments. Meanwhile, unsheltered homelessness among children under age 18 has practically disappeared. (The HUD surveyors could only find 2,000 of them--only one percent of the total unsheltered population.)
• Back in the 1980s and 1990s, homelessness was considered largely a problem of rootless kids and young adults. By the 2020s, it will be regarded as a problem of rootless seniors. Yes, these are the same people--growing older at the same rate that time passes.

• Because of today’s low fertility rates, the number of prospective college students is expected to decline sharply beginning in 2026. Colleges are likely to try to offset this decline by improving retention rates, with two-year and non-selective four-year schools facing the most pressure. (Harvard Business Review)
• NH: The American higher-ed industry already had to weather one demographic hit in the decade following 2008, after the peak 1990 birth cohort reached age 18. Subsequent smaller birth cohorts forced many colleges during the Great Recession to tighten their belts. Now another demographic hit is on the way. It will happen in the years following 2025, when the babies born in 2007--another high-tide birth cohort--reach age 18. After 2007, thanks to the tanking economy, total births began to sink again. And fertility rates (and immigration rates) have been falling pretty much every year since then.
• After the first hit, colleges made up much of the difference with an aggressive campaign to recruit full-tuition-paying students from abroad, especially from China. For a while, that campaign proved very successful. But starting in 2016 and 2017, the influx has ebbed. (See "Why Has Global Higher Ed Lost Its Luster?")
• More challenging for colleges, IMO, is the likely impact of a national policy effort to cut back tuition cost growth and student indebtedness by finding cost-effective substitutes for college degrees and by expanding the supply of institutions that can provide college-level credentials. (See "How to Control the Exploding Cost of Higher Ed.") That would put extra pressure of second- and third-tier liberal arts colleges--and possibly force many of them out of business.
• The median age of first-time home buyers has increased to 33, the oldest in records dating back to 1981 from the National Association of Realtors. The median age of all buyers has also climbed to a record high, 47, and is up for the third year in a row. (Bloomberg)
• NH: In August, housing starts jumped up to 1.39 million (SAAR), the highest monthly figure of this recovery. But in September, the number fell back down again, to 1.26 million, giving us the sense that housing has pretty much maxed out during this economic recovery. Over the last three years, it has been running at around one and a quarter million starts per year.
• If the number rises no higher, this will end up being by far the weakest housing performance during any recovery going back to 1959--when housing starts peaked (following the Eisenhower recession) at 1.67 million. Not bad for 1959, considering that there were only 43% as many American adults as there are today! (See "Household Formation: Why Is It Declining and Where Is It Going?")
• There are many drivers behind today's inferior housing performance. Houses are better built and last longer--which eliminates the discards that used to require replacement units. Overall population growth is slowing down, which means less growth in the number of adults who need to be housed. Millennial young adults are less able to afford to buy their own home--and are more willing to live with each other or with their parents. Fewer widows mean more seniors are living with their partners. High rental prices in many urban areas render housing entirely unaffordable for low earners.
• Reflecting many of these "crowding" drivers is the brute fact that household size (adults per housing unit) is no longer declining. It is rising. This shifting trend in household size has eliminated the need for well over a new million units over the last decade.
• The new NAR numbers add one more way to reflect on these demographic shifts. Not only are younger adults today more willing to "double up" with others in household formation, but they are also more likely to rent instead of buy. Hence, the rise in the median age of first-time homebuyers--from 31 in 1981 to 33 in 2019. The median age of repeat buyers has risen a lot more dramatically, from 36 to 55.

 

• South Korea’s declining birthrate poses a problem for the military, which is expected to shrink by 100,000 members over the next three years. The military plans to increase the use of surveillance drones and other unmanned devices to compensate, but as one former security official notes, “[there are] things only people can do.” (The Wall Street Journal)
• NH: When I first came across this story, I thought the ROK military must be exaggerating the impact of demographic change. But when I looked more closely at the numbers, I realized that this is no exaggeration. In fact, the planners may have to initiate much deeper cuts in future years.
• What's happening? The massive drop in total South Korean births during the late-1990s and early 2000s--caused both by fewer young women and by plummeting fertility rates--has produced a precipitous decline in the annual number of new adults today reaching their early 20s. Just take a look at the population pyramid (below).
• Today, there are 1.8 million males age 20-24, or 360,000 per birth cohort. With universal male conscription and service of two years, this can plausibly generate a standing force of 720,000 men. (ROK's actual force levels are more like 600,000, since actual service time is less than two years and some males cannot serve.)
• Now look ahead five years by counting the number of males today age 15-19. The number drops to 1.3 million. Do the same arithmetic, and you get a force of only 520,000 men. See the problem?
• President Moon Jae-in didn't make the challenge any easier by recently enacting (as he had promised when running for office) a 3-month reduction in the length of required military service. While Moon has suggested expanding female recruits on a purely voluntary basis, that won't generate more than a few thousand more recruits. Why not make military service mandatory for women as well? That would boost numbers in a significant way. Indeed, that is how North Korea maintains a slightly largely military force with only half of South Korea's population.
• If service duration cannot be lengthened, few other options are available. Planners may in time experiment with guest workers who serve in the military--aka mercenaries--if they have no opportunity to gain citizenship. Who knows? An open invitation to young North Koreans would be an intriguing idea.

DID YOU KNOW?

I’d Rather Be at Work. Given the choice between working outside the home or staying home to take care of the house and family, a record 66% of Americans would choose to work. That’s according to Gallup, which has been asking some form of this question since 1992. Women’s preference for working outside the home has consistently lagged behind men’s. This year is no different (56% for women, 75% for men)—but notably, women’s preference for working has climbed to its highest level in roughly three decades. However, there continue to be significant differences in opinion between women with children under age 18 and women without minor children. Fully half of women with children under 18 prefer to be homemakers, which falls to 34% among women without minor children. Women who aren’t currently employed are also more likely to prefer homemaking. Men, in contrast, broadly prefer to work regardless of their parental or employment status.