Like most doctors yesterday, I was in the busy seeing a full schedule of patients when President Obama addressed members of the American Medical Association at their annual meeting in Chicago.  The speech was billed as a crucial confrontation over health reform, and anticipation had been building for quite some time.   So I was too busy to learn anything about his remarks and the response until I got home.  

 Then again, I’m not a member of the AMA.  I never have been.  Neither are very many of my  physician friends and colleagues.  In fact, the odds are that your doctor isn’t a member of the AMA, because at best, only between 25-30% of the approximately 800,000 doctors in country belong to it.  And a good percentage (up to half of members according to one report) of those include residents and medical students, who get big discounts on membership and a free subscription to a journal when they join. 

Given those numbers, how relevant is the AMA?  And why did President Obama stump for health reform there?   

First, like so many influential organizations, the number of doctors who comprise the AMA matters less than their influence in the beltway—they still are a potent Congressional lobby with plenty of cash to spend.   

Second, since Barack Obama does his homework, he knows who and what he’s up against.  During the Great Depression, FDR wanted to make comprehensive health reform part of the New Deal.  In doing so, like Obama, he was forced to confront the AMA. We all know who won that battle, but think about how different things might have been if the AMA’s leadership had the foresight to see what a mess American health care has become today.   

Indeed, the AMA has a long history of winning wars.   Since its inception in 1847, the group has enjoyed many victories on its way to consolidating physician power.  To its credit, it helped raise the social stature of the medical profession in this country. Prior to its inception, medicine was a trade that included everybody from an educated MD (though the extent and depth of that education varied from medical school to medical school) to snake oil salesmen pushing miracle tonics to cure all your ills.  As it gained traction, the AMA helped to create and implement educational and licensing standards for doctors.   It also emphasized a highly scientific approach to medical care.  In many ways, therefore, the AMA is the reason our image of doctors is one of a white-coat wearing, cerebral and scientifically-minded group of professionals.    

But to its critics the AMA is nothing more than a guild that protects its own at all costs.  For example, it successfully marginalized non-physician health care providers (osteopaths and nurse midwives, for example). By doing this, critics state the AMA was able to control the price of health care through controlling the supply of the nation’s doctors.  The most absurd example of the haves versus the have nots were African American doctors. For decades, the AMA discriminated against black physicians (a policy that it finally apologized for last year).  

Probably the AMAs most lasting impact on American medicine has been its unconditional marriage to traditional fee-for-service medicine, which tilts higher incomes toward specialists and expensive tests and procedures.  That has have helped drive costs through the roof.  Because of that bias toward specialists, it’s also not a stretch to hold it responsible, in some ways, for helping to create the shortage of  primary care doctors in our country today (according to Matthew Holt of the influential Health Care Blog, the AMA’s membership “over-represents specialists and those in small practices.”). 

It’s also been an organization very weary of innovation. In California, during the Depression and Second World War, Dr. Sidney R. Garfield and construction magnate Henry J. Kaiser joined forces to create Kaiser Permanente, a health plan where Kaiser’s shipyard, steel and construction workers prepaid for their care, which was provided by doctors from different specialties.  It was one of the earliest, if not the first, example of integrated health care that focused on prevention instead of illness.  When the powers that be at the AMA heard about the Kaiser experiment, they perceived as a threat to the status quo (after all, for most doctors, a sick patient is what pays the bills), and discouraged doctors form joining it or attempting to emulate a model where health, not illness, was rewarded.  While the Kaiser model has been successful in California and several other parts of the country, the model has not yet spread widely (full disclosure: I’m a Kaiser doc—though my views here do not necessarily represent those of my medical group) 

All those victories, however, are in the past.  Today, with health care costs out of control, millions uninsured and underinsured and an incredibly-shrinking base of members, the AMA is vulnerable to the voices of reform.   Still, history teaches us that it knows how to protect its interests, even if those interests don’t  adhere to its motto “helping doctors help patients.” 

If you’re wondering just what its interests are are, look where the two greatest sources of tension are between the Administration and the AMA.  The first is the real possibility of creating a public insurance plan to broaden coverage and get more of the 48 million uninsured Americans relief. Publicly, the AMA hasn’t quite come out against the plan—in fact, the organization spent the better part of the weekend trying to “correct”  New York Times reports suggesting its opposition to it.   But there’s no doubt that the AMA doesn’t see “public option” as code for “socialized medicine,” and it worries about a lower cost public plan becoming the first choice for employers and individuals will force doctors profits down.

The next point of contention is tort reform, and limiting the scope and awards of malpractice suits.  As a doctor, it’s hard to argue against this point—many of us practice “defensive medicine” and order plenty of tests and drugs not out of necessity, but rather out of the fear of being sued. In reality, however—and as a piece in this week’s New England Journal of Medicine points out, nobody really knows how much defensive medicine contributes to the overall cost of health care.  Still, as the article points out, even if its 1% of annual GDP spending, it’s more than enough to justify some reform. 

But Obama isn’t backing down on tort reform either—he came out and told his audience yesterday that tort reform isn’t on the table because it’s not fair to those who may have been truly injured by a doctor. For that, he received some scattered boos from the audience.  Yet it’s probably not a very risky bet to make that the Negotiator-in-Chief will support some form of medical malpractice reform as a way to garner the AMA’s formal support for a public plan and other aspects of his package. 

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