By Danielle Carr
The Nation, February 6, 2020
Last month, two major physicians’ groups dealt a one-two punch in the fight for Medicare for All. On January 20, the 159,000-member American College of Physicians released a position paper arguing that a single-payer system or one with a robust public option would improve patient care and reduce costs. The next day, more than 2,000 doctors organized through Physicians for a National Health Program published a full-page letter in The New York Times prescribing Medicare for All for the nation.
Together, the actions signal the increasing militancy of doctors who no longer feel represented by the largest professional society in their field, the American Medical Association. Since its rise in the early 20th century, the AMA has served as the most powerful umbrella organization for physician advocacy and lobbying and has proved instrumental in defeating every campaign for national health insurance in US history.
That calls for single-payer are coming from outside the AMA reflects the reality that doctors are not a single class of workers with a unified political view. The American College of Physicians consists of doctors of internal medicine who largely work on the front lines of primary and preventive care, while the AMA is dominated by physicians practicing in lucrative specialty fields.
Even in the AMA, change is in the air. In June 2019, the medical students’ chapter introduced a proposal to strike down the AMA’s unconditional opposition to single-payer. The students were narrowly defeated, 53 to 47 percent, in the organization’s policy-setting House of Delegates. Pressure from within has forced the AMA to withdraw from the Partnership for America’s Health Care Future, an industry coalition of insurance and hospital lobbies opposed to single-payer. As public support for Medicare for All continues to enjoy widespread support, the AMA’s inflexibility increasingly looks as if it could disqualify the group from a seat at the policy-making table in the future.
The recent actions have a long history. In 1937 a group of 430 prominent doctors challenged the AMA’s blanket opposition to any form of health insurance, publishing a statement that was covered on the front page of the Times. In a direct rebuke to a decision that year by the AMA’s House of Delegates to vote against a national health program, the statement declared that “the health of the people is a direct concern of the government” and that “a national health policy directed toward all groups of the population should be formulated.”
The Times reported the statement as an indication “that open defiance of the authority of the [AMA] is spreading among many of the rank and file of American physicians who had been silently opposing the attitude of their leaders.”
The revolt occurred in the context of rising health care costs amid the Great Depression, leaving vast swaths of the population without access to care. A 1937 report funded by the Works Progress Administration revealed that over 30 percent of Americans with a serious illness or injury within the previous year were unable to afford needed medical treatment.
That year, a survey of 2,100 physicians confirmed the prevalence of profit seeking in the medical profession and gave voice to their call for solutions ranging from voluntary insurance to a national health plan. A study conducted by the Committee on the Costs of Medical Care revealed grave problems with the fee-for-service model, which resulted in spiraling prices and gaps in care.
The 1937 physician survey recommended group insurance and a reorientation toward primary and preventive care. But the AMA was vehement in its opposition to President Franklin Roosevelt’s intention to include health care in the 1935 Social Security Act. Facing a fiery political campaign by the organization to resist any “third party [coming] between the patient and his physician in any medical relation,” Roosevelt calculated the political costs and then dropped health insurance from the bill.
The collective action by the dissenting doctors was an effective move within the larger context of rising opposition to the AMA’s profit-driven agenda. Despite its original goal of reining in the free market, the AMA did little to restrain doctors from making as much money as possible, even when patient care suffered. The AMA’s opposition to any form of insurance was a dynamic typical of markets in which suppliers are organized and consumers are not. Protected from competition by a powerful industry organization, physicians could charge more for their services to patients, who dealt with costs individually.
By 1938, the government had begun to rethink its policy of allowing the AMA to regulate itself. Responding in part to revelations that local chapters of the AMA had punished physicians who accepted group insurance, the Justice Department charged the organization with a conspiracy to violate antitrust law for retaliating against doctors who broke ranks with “organized medicine.” Later that year, New Deal lawmakers aiming to remedy the absence of health care coverage in the Social Security Act convened a National Health Congress in Washington, DC, to gather information on the shortcomings of the fee-for-service model. The following year, Senator Robert Wagner introduced a national bill to help states fund public health insurance.
Although the AMA was saved from having to battle this plan by the outbreak of World War II, by 1945 the writing was on the wall. Faced with the creation of the National Health Service in Britain and widespread popular support for nationalized health insurance at home, the AMA was forced into the defensive position of endorsing private and employer-based insurance models as the solution to the nation’s health care crisis.
The AMA has long framed its opposition to nationalized health care as a defense of the individual freedoms afforded by the free market. The irony, of course, is that its founding mission was to limit the depredations of the unregulated market by halting the “free trade in doctoring” that characterized the United States until the latter half of the 19th century. It has consistently subverted health care reform to maintain the profitability of the care physicians provide. The resulting situation—with life expectancy lower and infant mortality higher in the United States than in comparable high-income nations, despite health care spending that is roughly double—is the consequence of policy half-measures: private and employer-based insurance instead of universal coverage, as well as federal subsidies for an industry charged with policing its own costs.
The current physicians’ revolt calls for an end to such half-measures. The American health care crisis has unfolded with one consistent theme: the profit-seeking factions of the medical profession attacking universal coverage to produce a fragmented group of medical consumers without organized power. Single-payer would put an end to the core failing of coexisting private and public coverage: Private insurers will always seek to offload those requiring the most expensive care onto the government payer.
The physicians’ 1937 rebellion called for a national plan that would provide for the entire population. After 70 years of attempts to achieve this through private or semipublic insurance, more and more doctors at the front lines of the health care crisis in America today are speaking clearly: Universal coverage can be achieved only through Medicare for All. The question is not whether these doctors will succeed in demanding reform but whether the AMA will finally join them.