By Jonathan Michels
Jacobin, January 9, 2020
Today, the American Medical Association (AMA) says it is the voice of American doctors. But it has long been a chief advocate of the country’s private health insurance system, which treats health care like a business and produces some of the worst health outcomes in the developed world.
Over the years, the AMA has lobbied against the passage of Medicare, obstructed civil rights campaigns to integrate hospitals and fight racism within the medical profession, and blocked or watered-down reforms that would limit the power of the health insurance industry.
Nowhere is the AMA’s intransigence more evident than in its nearly one-hundred-year-old opposition to publicly financed health care and especially single payer (Medicare for All, in today’s parlance).
Yet in a surprising move last August, the AMA abruptly withdrew from a corporate front group that aims to stymie the Medicare for All movement. The benign-sounding Partnership for America’s Health Care Future consists of nearly sixty organizations representing private health insurers, medical device manufacturers, and pharmaceutical and hospital executives.
“The AMA dropping out of the Partnership is very significant,” said Wendell Potter, a health industry executive turned whistleblower who regularly attended meetings in groups just like the Partnership. “It has to be seen as a big loss to the Partnership because the AMA is so well known and has been a reliable partner in years past.”
That isn’t to say the Partnership has let up. Last month, the Washington Post reported that 50 percent of all political advertising in Iowa ahead of the Democratic caucus had been paid for by the Partnership. You can also see the Partnership’s influence in their million-dollar attack ads broadcast during the 2020 Democratic presidential debates and on the lips of Democratic Party insiders parroting Partnership talking points to “build on what’s working in health care” rather than fighting for transformative reform.
So why did the AMA decide to leave? The AMA’s departure may have been an attempt to preserve its credibility in the face of a discredited health care system that it helped create and a response to mounting pressure within its own ranks. What we shouldn’t see it as is a surrender in the AMA’s war against health justice — a war it’s been waging for too long to quit now.
“AMA: Get Out Of The Way!”
This past June, physicians convened for the opening session of the AMA House of Delegates at the Hyatt Regency in Chicago. The well-dressed guests and the plush accommodations could have been any business convention or a meeting of the Fortune 500.
And then: raucous noise.
Demonstrators, led by disabled activists from ADAPT and a contingent of senior citizens, marched into the Hyatt Regency conference hall chanting loudly. Having breached hotel security, the group made their way to the conference hall holding cardboard protest signs carved into the shape of tombstones. Now face-to-face with the stunned doctors, the protesters dropped to the floor to symbolize the roughly 39,000 people who die unnecessarily each year due to lack of health insurance.
In front of a lectern splashed with the AMA logo, Susan Aarup, a disability rights activist, commandeered the meeting and proceeded to school the assembled professionals about how their health reform policies have negatively impacted her life.
“I had to go to the pharmacy because of a bladder infection,” Aarup yelled. “When I got to the pharmacy I found out they cancelled my health insurance.”
“That’s not right,” she said. “We need Medicare for All!”
Simultaneously, five hundred doctors, medical students, nurses, and other health care activists converged outside of the annual meeting to deliver a simple message to the AMA: drop your membership in the Partnership for America’s Health Care Future. Support Medicare for All or get out of the way.
“With AMA members comprising only 15 percent of physicians, they are not the voice of doctors anymore, and they definitely do not represent me or my fellow medical students,” Rush University medical student Alankrita Siddula told the crowd. “America has had enough, and Medicare for All will happen, whether the AMA is with us or not,” she said.
Two months after the demonstration, the association left the Partnership.
With its credibility on the line, the AMA’s withdrawal may represent a public relations concession to the protests. But it could also reflect strategic differences among members of the Partnership on the most effective way to kill Medicare for All.
What we see from the history of the AMA’s lobbying efforts is that its success often hinges on manipulating the US public’s trust of physicians to first outright oppose bold reform measures and then harness incremental reforms like the Affordable Care Act (ACA) that actually strengthen market forces.
The Partnership has made it clear that it will continue to oppose any reform option that seeks to expand government participation in health care. The AMA, in contrast, is opting for the appearance of open-mindedness, putting forward a slate of modest proposals to expand “access” to private health coverage under the ACA, which has also ensured more revenue for hospitals and physicians. “The AMA decided to leave the Partnership for America’s Health Care Future so that we can devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our health care system,” AMA CEO James Madara told Politico after the announcement.
Former AMA president Donald Palmisano put it more clearly.
“I think we ought to put a stake in the heart of single payer,” Palmisano told the House of Delegates following the June protest. “We’ve done it before; we ought to do it again.”
A History of Exclusion
The AMA was founded in 1847 as a guild whose primary mission was to protect the business interests of physicians (overwhelmingly white and male) against encroachment from adversarial medical practitioners, competing interest groups, and the government. The AMA portrayed its efforts to professionalize medicine as guided by American ideals like individualism and freedom. What went unspoken was the role that money played in the AMA’s policy decisions even when it came to opposing efforts that sought to ameliorate patient suffering.
“The leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat,” notes historian Christy Ford Chapin.
“A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these ‘alternative’ plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.”
During the Jim Crow era, AMA leaders looked the other way when their Southern affiliates barred African-American physicians from becoming members. Their exclusionary policies helped grow the National Medical Association, a professional organization founded by black doctors that vocally supported single-payer health care when few physicians’ groups would even touch the issue.
The AMA eventually managed to exert control at every level of the medical profession. A pamphlet distributed to doctors in 1953 summed up the group’s dominance: “The Association began helping you the day you entered medical school and continues to aid your practice and guard your freedom. Even if you are not a member, it is your AMA to a certain extent.”
The public’s growing faith in doctors as the purveyors of scientific progress, meanwhile, endowed the AMA with prestige and credibility. Hospital administrators eagerly ceded control of medical care delivery to AMA doctors. Elected officials clamored to win the association’s support, afraid of paying a price for challenging the “voice of American medicine.”
Simultaneously, the AMA inculcated in patients the idea that medical care is a transaction tied to the marketplace and not a right.
In 1915, a group of progressive academics with the American Association of Labor Legislation (AALL) devised a plan to provide social health insurance for workers with the hopes of offsetting the physical and financial burdens associated with poverty and disease.
The AMA briefly supported the AALL plan in New York, to be funded by contributions from workers, employers, and the state, but the association’s conservative wing reversed course in 1920. The first shot in the AMA’s war against single payer was fired that year when 90 percent of the House of Delegates voted to oppose “any plan embodying the system of compulsory insurance … provided, controlled or regulated by any state or the Federal government.”
While the AALL plan won support from several interest groups, its prospects wilted because proponents placed too much emphasis on securing the backing of medical societies like the AMA instead of mobilizing workers themselves. More successful, writes Beatrix Hoffman in The Wages of Sickness, were employers and commercial health insurers, who amplified the AMA’s agenda by constructing their “self-interest as the public interest” in concert with one another, presaging coalitions like the Partnership.
The movement for national health insurance picked up steam again after World War II as labor unions pushed a single-payer plan and Harry Truman declared “health security for all” a top priority of his nascent presidency. Two-thirds of the American public supported Truman’s proposal for a national health insurance program.
An alarmed AMA stated beating the war drums. In 1948, it enlisted Campaigns, Inc., the world’s first political consulting firm, to lead the attack. Armed with a $5 million war chest amassed from $25 AMA membership fees, Campaigns, Inc. oversaw the delivery of 55 million pieces of propaganda, blending Cold War hysteria with nationalistic fervor that denounced single-payer health care as “socialized medicine.”
At the same time, the AMA recognized the potential of the burgeoning private health insurance market to keep single payer at bay. “The Voluntary Way Is the American Way,” AMA doctors told patients. The campaign was “the largest political offensive ever waged against a single piece of legislation in U.S. history,” Chapin writes. By the early 1950s, the movement for a national health program lay in ruins.
Not content to simply fight single payer, the AMA also provided cover for Jim Crow. It continued to justify its Southern medical societies’ discriminatory membership policies against African-American physicians as well as the association’s refusal to take a stand against segregated medical services, which threatened the health of millions of people.
Speaking to doctors with the Medical Committee for Human Rights (MCHR) in 1966, Martin Luther King, Jr excoriated the AMA for perpetuating racism in medicine and abdicating its moral obligation to advocate for the right of all people to quality health care. “Of all the forms of inequality,” King said, “injustice in health is the most shocking and the most inhuman because it often results in physical death. I see no alternative to direct action and creative nonviolence to raise the conscience of the nation.” On four separate occasions in the 1960s, physicians with the black-led National Medical Association marched alongside members of the MCHR and King’s Poor People’s Campaign to protest the AMA’s complicity with Jim Crow racism.
At the same time, many of these progressive forces were battling to ensure health care for seniors and the very poor. By fusing civil rights with the human right to health care, Medicare and Medicaid supporters were able to put forward a moral argument that even the AMA found difficult to spin.
Faced with the loss of millions of dollars in federal reimbursements, hospitals and the AMA conceded to these publicly funded programs at the zero hour.
“After Medicare’s passage, the reputation of the AMA as a collection of compassionate experts laboring for the public good lay in tatters,” Chapin writes.
Internal divisions within the AMA were further exacerbated when the organization’s own student section dissociated themselves from the organization over its refusal to support universal health care and civil rights. By the end of that decade, the association disavowed its discriminatory membership policies to save face.
In recent years, the AMA has taken a more progressive stance on certain issues, calling for more diversity in medicine and standing up for immigrants with DACA status. But the AMA has never addressed King’s fundamental concern: the continuation of an unjust and inequitable health care system.
Overcoming Entrenched Private Interests
The heated debate over Medicare for All comes at a time when more and more Americans are struggling under the weight of our deplorable health system. Despite the Affordable Care Act, 28 million Americans remain uninsured and an additional 41 million are underinsured. Even those with coverage often face impoverishment and bankruptcy from rising premiums, co-pays, and deductibles.
Each day brings fresh revelations about American drug companies’ disgusting opioid racketeering, which has fueled a public health disaster that claimed the lives of 47,000 people in 2017 alone. Giant nonprofit hospital systems, meanwhile, are coming under fire for suing their patients, garnishing their wages, and even seizing their homes in order to claw back the medical debt they incurred at their sickest and most vulnerable. No wonder some polls show upwards of 70 percent of the public supporting Medicare for All.
The AMA and its corporate allies are finding it more difficult to turn medical providers and patients away from Medicare for All with the same old scare tactics and half-measures. The reason for forming corporate front groups like the Partnership for America’s Health Care Future was to allow some of the most reviled industries in the United States like Big Pharma and private health insurance corporations to pool their resources while avoiding the appearance of being self-serving for attacking Medicare for All.
But the AMA’s departure is not the end of the corporate partnership to kill Medicare for All. Big Medicine, Big Pharma, private health insurance: they might at times appear to be competitors but when it comes to keeping health care in private hands and a steady source of revenue, they stand as one.
“They all point the finger of blame at each other publicly to divert any responsibility away from themselves for the problems that we have in our health care system,” Potter said. “Behind the scenes, they work together very closely when there is any threat to the status quo because the status quo largely works for all of them.”
Along with public support for Medicare for All, the AMA will also have to contend with increasing dissension among its base.
The AMA might still be the most prominent and powerful physicians’ group in the United States. It might still wield influence within the medical community through its Journal of the American Medical Association (JAMA) and in Washington, DC where it is the third largest lobbying group, behind only the National Association of Realtors and the US Chamber of Commerce.
But the AMA is not the sole voice of US doctors. An estimated 15 percent of doctors in the United States are AMA members, a precipitous drop from the 1950s when the organization claimed three-quarters of American physicians. The AMA’s power has been diffused by the rise of specialty physicians’ organizations as well as the founding of groups like Physicians for a National Health Program (PNHP) that provide an outlet for disgruntled doctors who feel hamstrung by corporate health care.
As a profession, doctors have been among the most adversely affected by the domination of the private insurance industry. Concern over physician burnout, rising student loan debt, and a sense of powerlessness in combating the racial and economic inequities unique to US medicine continues to fuel the explosion in single-payer activism on medical school campuses across the nation. A survey conducted by the AMA-affiliated Chicago Medical Society that found that the majority of practicing US physicians now support a single-payer system.
There is also clear evidence that AMA members themselves are split on the issue of single payer. In the wake of the June protest, 47 percent of the AMA House of Delegates voted to rescind the association’s opposition to national health care, leading some to speculate that it is only a matter of time before the association supports Medicare for All.
That might be too optimistic. The history of the AMA’s endless war against single payer suggests that if Medicare for All is defeated, it will most likely die with a target on its back from the AMA.
Yet the cracks forming within the AMA and the broader physicians’ community also bode well. We may just be able to win a giant step toward health care justice after all.