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The Federalist Papers and Why Doctors Must Vote

James Madison wrote in Federalist No.52, “The definition of the right of suffrage is very justly regarded as a fundamental article of republican government.” In addition, although some controversy surrounds the attribution, Thomas Jefferson is thought to have said, “An educated citizenry is a vital requisite for our survival as a free people.”

Despite these admonitions of our Founding Fathers regarding the privilege and importance of voting, physicians have a poor track record as participatory citizens. A recent article reported data that doctors are 9% less likely to vote than the general population and 22% less likely to cast their ballots than lawyers.1 A New York Times letter to the editor urged physicians to vote themselves in addition to encouraging their patients to do so as well.2

The importance of physicians participating in the election process goes beyond just national issues. Former Speaker of the House, Tip O’Neill, once said, “All politics is local.” He was right. In the U.S. in the 2018 election, there were 155 local ballot questions in 37 states. The ballot questions ranged from Medicaid expansion in Nebraska, Idaho, Utah and Montana, and mandatory nurse staffing rates in Massachusetts to placing caps on profits of kidney dialysis providers in California.

Doctors have, to a large extent, relinquished their role as local leaders and experts in health care issues. Besides going to the voting booth on election day, physicians should leave articles and their own commentaries on health issues in their waiting rooms as a service to their patients. They should write letters to the editor of their local newspapers and participate in PACs and local campaigns when possible. I recently served as a health policy adviser to a former high school classmate who was running for the U.S. Senate. It was extremely rewarding and I learned a great deal about the election process. I would encourage other urologists to become actively involved in political campaigns.

The Unique Role of CJU

Health care reform continues to evolve in both the United States and Canada. The Canadian Journal of Urology (CJU) occupies a unique role in facilitating dialogue and information exchange between American and Canadian urologists. Bernie Sanders has been a strong advocate in the U.S. of single payer health care. However, single payer proposals continue to engender controversy in the United States.

It has been estimated that “Medicare For All” would cost $32.6 trillion dollars over 10 years.3 Several recent state proposals for universal health care have failed. In 2016, “Colorado Care”, Amendment 69, was defeated on the ballot by an almost 4 to 1 margin, 78.77% to 21.23%.4 Similar proposals in California (S.B. 562 Healthy California) and Green Mountain Care in Vermont were abandoned before reaching the ballot because of what were considered prohibitive costs.5,6

However, Canada has had experience with universal coverage since the implementation of the Canada Health Act of 1984. Many reports concerning health care in Canada are laudatory. However, some commentaries have provided a cautionary tale. A recent editorial by Scott W. Atlas in the Wall Street Journal provides some sobering statistics.7 He reported that the median time between seeing a general practitioner and a specialist in Canada was 10.2 weeks. He added that Canadians with heart disease waited 3 months for a cardiology appointment and wait times for hip or knee replacements started at 10 months.

Sally Pipes reported additional alarming statistics regarding wait times in the Canadian system.8 She quoted the Fraser Institute report in Vancouver, that in 2017, more than 173,000 patients waited for an ophthalmology procedure, 91,000 waited for a general surgery procedure and more than 40,000 waited for a urology procedure.

These data are concerning and are contrary to the expectations of most Americans. The debate regarding a single payer system in the United States is sure to occupy center stage in the 2020 presidential election. It is therefore imperative that there continues to be dialogue between U.S. and Canadian physicians about the pros and cons of the Canadian system and its applicability to the United States. One relevant consideration is the heterogeneity and sheer size of the U.S. population relative to Canada’s (325 million versus 36 million).

One of the critical issues moving forward in the U.S. will be physician participation in the ongoing health care discussion. Inherent to this participation will be physicians voting in far greater numbers. In Federalist 53, Madison continues his admonitions about the importance of voting when he says,” that where annual elections end, tyranny begins.” Physicians are busy people with many responsibilities. However, we need to remember the wisdom of Madison in the Federalist Papers and fulfill our obligations as informed citizens. Physician participation in the entire electoral process is our responsibility to our society, our profession and our patients.

Kevin R. Loughlin, MD,
MBA Harvard Medical School Boston, Massachusetts,
USA Associate Editor


1. Grande D, Asch DA, Armstrong K. Do Doctors Vote? J Gen Intern Med 2007;22(5):585-589.

2. Loughlin KR. Doctor, Get Thee to the Polls. Letter to the editor, NY Times 10/25/18, A 26.

3. Alonso-Zaldivar R. “Medicare for All” Would Cost $32.6 Trillion Over 10 Years, Study Says. Associated Press 7/30/18.

4. Creation of Colorado Care System, Amendment 69 (2016)., accessed 12/26/18.

5. Healthy California Act SB 562-Single Payer Healthcare. https://healthycalifornia health care reform. accessed 12/26/18.

6. Atlas SW. The False Promise of “Medicare For All” WSJ 11/12/18.

7. Pipes S. Canadians Are One In A Million-While Waiting For Medical Treatment. Forbes 6/11/18.


© The Canadian Journal of Urology™; 26(1); February 2019