Live in the US? Uninsured? Underinsured? In the Medicare donut hole? Stuck in a job you hate because you need the benefits? Thank the AMA.
Medicare was proposed in the 1930s when Social Security was enacted. You may have noticed that Medicare didn’t actually exist until the 1960s. That’s in large part because the AMA spent millions of dollars fighting it. Can’t have the government telling doctors what to do, or how much they can charge. It’s an article of faith with the AMA that doctors must be allowed to do their work without any pesky oversight at all.
The AMA was so desperate to keep the government from running medicine that they continued to fight any expansion of Medicare benefits. The original plan, in the 1930s and again in the 1960s, was that Medicare for seniors would be the first step toward universal health care. That was actually a campaign issue in the 1972 Presidential election – and not just a plank in McGovern’s platform, but in Nixon’s as well. Instead of expanding Medicare, we continued the practice of giving employer-based health insurance special tax benefits, which helped corporations and those who were employed by corporations and left everyone else, well, out.
For a while that worked kind of OK, at least for the people who counted (employed, financially stable, married to someone who was employed). Medicare and private insurances paid hospitals and doctors well enough to keep the charity care programs running, too, although the quality of care was questionable. But then there was an explosion of medical technology in the 1970s and 80s. At the same time, the post-WWII economic expansion in the US finally slowed and stopped. Medical costs became a larger and larger part of overall US expenditures. As employment patterns started to change, more people lost insurance and couldn’t afford care at all.
Of course the AMA noticed this; they swung right into action. They fought any attempts to limit reimbursement to doctors. Medical costs spiraling out of control? Don’t blame to docs! Payments to doctors are a small part of the costs! What they never bothered to mention is that the high-tech testing that made up a much larger part of the cost increases were done under doctor’s orders, and often without any evidence that they benefited patients. The AMA opposed the development of practice guidelines, too – remember, no pesky oversight.
Then it was the 1990s. Bill Clinton is elected, and he asks Hillary to head a task force on health care. We know how that ended, and the AMA had its hand in that, too. But then the health care system changed anyway. The AMA had successfully fought off “socialized medicine”, only to find that docs were now dealing with corporate medicine. And it turns out it’s not just oversight they hate, it’s salaries. When Kaiser started in the 40s in California, the AMA declared that taking a salary ran contrary to the Hippocratic oath. Kaiser docs weren’t welcome in the California Medical Society until the late 1960s. When I chose a Kaiser residency, at least two people told me I was abandoning the ethics of my profession. My experience at Kaiser was that docs made the decisions. Doc I knew and trusted and worked with. Yes, they have limited resources – but we all have limited resources. At least in the Kaiser system the resource utilization decisions were transparent and made by doctors, for the most part.
No system is perfect. All systems have perverse incentives, and there are bad docs everywhere. Most of us are well-meaning, but we’re all human; we will do what benefits us if we can. At the moment, everyone is losing, and the patients are losing more than the docs. If we had a single-payer system, everyone could have basic medical care. We could put resources into preventive care, screening, prenatal care, health education and risk factor modification instead of trying to rescue people from the ravages of preventable disease. I could have one formulary instead of trying to remember which insurance company wants me to use Lipitor and which one wants me to use generic simvastatin. Rich people would still get different care. That won’t ever change. But no one should have to be rich to get care in the first place.
We already have health care rationing, because we have people who can’t afford their medications or can’t get access in the first place and we have people getting too much care. It is possible to do more with less, to get rid of the bloated bureaucracies and the ridiculous competition for cherry-picked insurance pools and use that money to actually provide medication. We’re not doing that now, and if those colors don’t look right to you, blame the AMA.