The AMA’s 20th century role in stopping National health insurance in the US
Origin & Historical Background of the AMA:
In the 1800s, two out of every three physicians were non-MD homeopaths and the cost for medical services was very modest. Low fees and a glut of medical practitioners drove down the average income of MDs to little more than the weekly wage of a mechanic. Inadequate compensation, low social status, lack of uniform educational standards and other issues stimulated allopathic physicians to consider organize themselves into state and local medical societies with membership restricted to MDs.
In response, Dr. Nathan Smith Davis, MD founded the American Medical Association on May 11th, 1846 as a loose configuration of state and county medical societies. It’s MD leaders hoped that doctors working together would remedy that long list of problems noted above. In the beginning, these state and local organizations of the AMA had little or no influence at regional and national level. However, all was not lost.
Moving up in the world – JAMA & other professional Journals
Just twenty years after the AMA was chartered, 1869 to be exact, Dr. Davis and the staff of the Association’s national office published its first professional journal – the Archives of Ophthalmology and Otology. In 1882, they published the Archives of Dermatology and a year later (1883), the Association’s began publishing it’s all-time most important journal, the Journal of the American Medical Association.
Fortunately for the organization, JAMA and its other journals were very profitable. Selling advertising space financed the upfront costs of publication and distribution. Handsome subscription fees by its own membership and various libraries — public, collegeal, and medical schools — provided even more income than the Association’s membership dues.
Best if all, favorable publicity and high esteem accorded JAMA greatly increased the Association’s “name recognition” and prestige as a national entity. This brought in additional revenue from subscriptions and advertisers.
Phase One: AMA as a loose confederation
During the first phase of its existence (1846 to 1899), political attempts by the Association to favorably influencing policy at the national level were disorganized and largely unsuccessful. The AMA’s loose confederation of state and county medical societies were ineffective because its MD members were more interested in local politics and exerting control over their own county medical societies.
During the last half of the 19th century, the AMA’s plan to control the practice of medicine wasn’t working as expected. This was extremely disappointing to its leaders and its membership and caused many to question the effectiveness of the AMA as a professional organization.
A loose confederation changes into an 800 pound gorilla
Phase two of the Association’s ascendancy began in 1897, when it was decided to take on a new posture of political activism. At that time, the AMA incorporated itself as a nationally-based organization that included all state and county medical societies as chartered members of the AMA, thus inventing the model we now think of as “organized medicine”.
Dr. George Simmons was elected Secretary of the organization and editor of JAMA in 1899, a leadership position he held for next 25 years. In 1901, he was also hired as the Association’s general manager. Under his influence, the AMA’s first permanent national office was opened in Chicago in 1902, and a full time staff was hired. By the end of the decade, the AMA had become (and has remained) the single most important social and political influence over health care policy in the United States. Since 1943, the AMA has also maintained a permanent office in Washington, DC.
The AMA’s goals were extremely ambitious — taking control of the country’s medical schools, eliminating all those that taught (or tolerated) non-allopathic “healing arts” or accepted women, immigrants or black as students.
To achieve this legal monopoly over the practice of medicine required the Association to convince or arm-twist state legislatures all across the country to officially adopt to the AMA’s criteria for medical licensure. From the AMA’ perspective this would eliminated the competition from other health and medical disciplines, such as homeopathy, naturopathic osteopathy, chiropractic, nursing and midwifery.
Only MDs who graduate from AMA approved medical schools were eligible for licensure and legally allowed to practice.
Historians give credit to the AMA’s first general manager for engineering the Association’s dramatic and amazing transformation. Doc Simmons, as he was always called, was a colorful personality who had number of different careers and something of a shady past before being hired to run the AMA in 1899. He was an odd but ultimately effective choice in the AMA’s phase two re-invention of itself.
In 1870, when George Simmons was 18 years old, he emigrated from England to Lincoln, Nebraska. There he became the editor of the Nebraska Farmer, a weekly newspaper. Sometime later he worked as a field correspondent for the Kansas City Journal. While he never went to medical school, he began to practice medicine in 1884 as a homeopath physician and eventually purchased a medical degree from a diploma-mill. His newspaper ads stated that he was a “specialist in the disease of women”, that he’d studied in the “largest hospitals in London and Vienna” and was a “licentiate of the Rotunda Hospital in Dublin”. While these claims were later proven false, he nonetheless practiced obstetrics and gynecology and ran a private clinic for women, where he delivered babies and performed unnamed surgical “procedures”.
In the late 1890s, he switched careers again, this time using his background in journalism to found and become editor the Western Medical Review. As his political connections grew, he was appointed secretary of the Nebraska Medical Society and the Western Surgical and Gynecological Society, where he developed a reputation for political effectiveness. Within a short time he became an officer and policy setter for the AMA.
But after 25 years as the AMA’s chief architect, disputes in the top echelon resulted in a public scandal over his lack of legitimate credentials as a medical doctor. Some even insisted that his practice of gynecology at his private hospital included doing abortions. True or not, he was forced to resign his appointment as Secretary of the Association in 1924. However, his long tenure as general manager, editor of JAMA and behind-the scenes political boss did not end until his death in 1937. Considering the scientific changes that ‘modern’ medicine under went during those 38 years, this is an astonishing reign of influence for any one individual.
Political Legacy: During the early years of Simmons’ influence over strategy, official of the AMA framed the policy issues of medical practice as too complicated for the ‘lay public’ to understand and to crucial to be trusted to the democratic process.
As a result, they were able to convince the United States Congress that it was in the public interest for the medical profession to control the health care system. During this time, the AMA’s membership surged from 8,000 in 1901 to 50,000 by the end of the decade.
Politically-speaking, the AMA has been the third rail of government since 1910. It continues to define model of medical practice the US as allopathic, while preventing our healthcare system from providing access to non-allopathic form of care.
The Publishing Empire Power Behind the Throne : Historic & Present
Originally, the bulk of the AMA’s money came from selling advertising in its professional journals, publications, beginning with the Journal of the American Medical Association JAMA. The most lucrative aspect of JAMA has always been ad revenue that came from selling advertising space to drug companies and medical devices manufacturers.
However,monopoly on medical services originally crafted by the AMA over the last 150 years ago. Today, control of this monopoly is financed by the AMA’s $300 million in annual revenue, which underwrites a multi-million propaganda budget. This bottomless wealth comes from the AMA’s publication of its diagnostic (ICD), which change every few years, and it’s proprietary billing codes (CPT) that it developed in 1930. Today every individual or organization that uses CPT content must purchase an annual license from the AMA.
Purchase of the AMA’s ICD official codebook (International Classification of Diseases) is $60 to $75 dollars apiece and 90% of healthcare providers and institutions have to use this information. New editions are published every couple of years, with ICD-10-CM being the most recent.
Some years ago, an online report (a “Hoover Profile” of the AMA) mentioned that the AMA had begun to sell the data collected by its huge national data base to healthcare business, providing a numerical record of the diseases and injury codes that are “trending”, as well as information on drugs used and other medical treatments and surgical procedures. This allows them to figure out what areas of medical care will be most profitable.
The Sunbeam Corporation, the AMA’s “Seal of Approval” as a new revenue stream and a deal gone bad
Another lucrative revenue stream for the AMA came from its vaulted “Seal of Approval”. This included deals made in exchange for products advertised in JAMA and its other professional journals which receiving the AMA “Seal of Approval” as part of a business agreement (not reflective of any scientific proof of safety or effectiveness). Over the course of several decades, various health foods, cigarettes (stopped in 1953) and a host of medical devices (such as its 1998 deal with the Sunbean Corporation for marketing its home medical devices) received the AMA’s Seal of Approval.
In addition to advertising revenue and selling very pricey subscriptions to its professional journals to libraries and educational institutions, the AMA also sells malpractice insurance and received many generous corporate grants.
While we think of the AMA as a professional trade organization representing MDs, its income, prestige and ability to set the agenda of medical professionals and shape public opinion came directly from its publishing business. This is no less true today than it was in 1910. As a result it does not have to rely on its membership for the $300 million a year that currently fuels it’s aggressive lobbying activities.
Within the world of special interest groups, the AMA reflects the very specialized corporate interests of the organization itself, rather than the medical profession per se or any public-spirited advocacy for national health care policy.
A Brief and Sordid History of the American Medical Association and Modern Medicine
Failed national healthcare policy that have fallen off the public radar
For all the dissatisfaction with our current system, the health care debate in the US has never questioned our MD-centric system or acknowledged the value of non-physician practitioners as cost-effective primary care providers. While we collectively appreciate the excellence of ER physicians and ability of the medical and surgical teams to treat those with life and limb-threatening emergencies, those of us who haven’t had a heart attack or car accident must face one of the most entrenched and pervasive failures of the current system — lack of access to health care, especially non-urgent primary care, ever-escalating costs, medical errors, hospital-acquired infections, and 20,000 preventable deaths annually because insurance is unavailable to 46.6 million Americans.
While chokepoint medicine guarantees total control of physician income by organized medicine, it is a failure as a national healthcare policy. Its time to replace this 19th century thinking with a 21st century partnership between MDs and non-physician primary care practitioners that puts the needs of society ahead of an out-dated idea of a physician-centric “traditional pattern of practice”.
Comparative Effectiveness ~ the lynch pin of an efficient, effective and affordable health care
The biggest missing piece in the health care debate is public discussion on the comparative effectiveness of health care methods and products. As noted, analyzing comparative effectiveness is distinctly different than the current, strictly defined evidence-based medicine — one is the forest, the other deals with individual trees. Comparative effectiveness takes the biological sciences up to a whole new level by analyzing the entire spectrum of the “healing arts”, as well as life-style issues, diagnostic technology, medical devices, treatment regimes, surgical procedures, institutional vs. out-patient or home-based care, etc.
Only a science-based analysis that relies on established effectiveness can correct the excesses associated with a century of unbridled, often irrational medicalization and repair the unnatural split between the art and the science of medicine that occurred in 1910. Its ability to restore marital harmony between the art and science of health care makes comparative effectiveness the lynch pin of an efficient, effective and affordable system for the 21PstP century.
A Vision for 2020: Affordable healthcare versus The 2nd federal bailout of the 21st century
The model of medical care developed by the AMA between 1904 and 1912 simply cannot work — it lacks the basic element of success and absolutely no amount of money can change that. Leaving healthcare reform to organized medicine and other special interests groups is like depending on Wall Street to fix the financial crisis by allowing the banks to issue a new round of credit default swaps. But it’s not too late to introduce scientific analysis of comparative effectiveness into health care and in doing so, correct the many problems we see in the current bloated and unresponsive system.
Do or Die: Failure to be politically effective is to risk an economic meltdown in the next decade that can easily trigger the second greatest recession-depression of the 21st century, one that will make the money spent on the toxic asset bailout look like chump change. Should we have a public health emergency of any kind, there will be no funds or reliable system to do what health care is suppose to do – meet public health needs that can’t be address any other way.
What Works: Only a rationally-based process can break the ever-escalating cycle of health care spending, defuse the impending baby-boomer-Medicare crisis, and provide an economically-level playing field which gives American business a fair shot at competing successfully in the global economy. Only by identifying the economic and practical roots of this problem can it be successfully addressed and only then will legislative reform not controlled by the AMA and its allies be able to prevail.
It was a fluke of history that brought us to this juncture — temporary goals of organized medicine in 1901, doing their best to make sure that medical doctors made a decent living and got the respect they deserved. These policies conflated the general category of health care with a specific subset of treatment, in this case, the discipline of allopathic medicine.
Unfortunately, state laws passed in the early years the 20th century were over-broad in defining an unlimited scope of practice for MDs. By granting exclusive control over all “mental and physical conditions”, the historic configuration of health care as a multi-disciplinary form of care (HealthCare_1.0) was eliminated. An unnaturally burdensome and increasingly dysfunctional and expensive system that defies common sense displaced health care as a broad-based, multi-disciplinary system that offered choice and controlled cost thru legitimate competition.
The lobbying efforts that have dominated healthcare policy, eliminated patient choice and triggered a hundred-year detour around universal coverage since 1920 were an extraordinarily successful expression of the democratic process. The biggest problem with well-funded lobbying by organized medicine was (and is) an unfunded and disorganized push-back by the public. Political power is naturally out-of-balance as long as it is one-side. It is still true that absolute power is uniquely vulnerable to becoming corrupted.
The good news is that it doesn’t have to stay this way. The medical politicians who orchestrated these events are long dead and that era has thankfully passed away. In our lifetime, conventional or “modern” medicine has earned its place as one of the most important and most central pieces of the health care system. However, it is still only of part of the whole. It doesn’t ‘own’ our personal health and it doesn’t work for it to ‘own’ our national health care system. Nonetheless, all the players in the health care drama have something valuable to contribute and there is a place for everyone – private and public, corporate and not-for-profit, allopathic and non-allopathic, physicians and non-physician practitioners.
For policy reform to work, we must design a system that is equally beneficial to the insured and the uninsured alike and one that addresses the legitimate concerns of each sector of the health care continuum.
One of the most crucial steps is a fair and rational process that includes analyzing the comparative effectiveness of different health care models, medical technology, treatments, devices and procedures. Only then can systemic effectiveness be synthesized with evidence-based medical treatment to give us ‘best’ practices that are based on authority, scientific evidence and comparative analysis.
By making health care effective, we also make it affordable. With an affordable system, universal access to money-saving, health-preserving care is not just economically possible, but an economic imperative. We can’t afford not to cover everyone!
Comparative effectiveness re-writes the playbook. It gives us a new start and a level playing field. Over time, a new perspective will develop in the social, political and economic realm and we will find ourselves with a health care system that is both healthy and caring and doesn’t break the bank. This win-win solution is as American as apple pie and best of all, it is good for everybody – ordinary people, health care providers, business and our democratic form of government.
This is the story that needs to be told and retold until every newspaper, blog, talk-show host, politician and political pundit gets it right.
