The American Medical Association: Power, Purpose, and Politics in Organized Medicine

THE AMERICAN MEDICAL ASSOCIATION: POWER, PURPOSE, AND POLITICS IN ORGANIZED MEDICINE TABLE OF CONTENTS PAT: I. INTRODUcrION .......... .................... 933 II. THE AMA STRucru... .. ................. 933 A. Membership ....... .................. 933 Reasons for membership ..... .............. 939 Reasons for son-mcmbership .... ............ 941 B. Formal Structure........ ................. .042 C. Real Power Structure ..... ............... 944 III. SOURCEs OF AMA PoIVE1 AND INFLUENCE. ..... ........... 947 A. Power over the Profession ..... .............. 948 Consent ....... ................... 948 Monopol............... .................. 943 Coercion.. ....... .................. 949 B. The FinancialBasis of Powacr ....... ............. 953 C. The Political Basis of Power ...... ............. 954 Prestige . 954 Mastery of political tactics . 954 Legal recognition..... ................ 959 IV. THE AppLcAToN OF AMA Powm ............. 959 A. Promoti g the Qvality of Medical Serces ... ......... .959 Scientific activities ..... ............... 959 Post-graduatemedical education ..... ........... 961 Services to the public ...................... 92 B. Setting the Qualitative and Quantitative Standards for Mcdical Practitioners........ ................. 963 The campaign against non-medical practitioners ...... 953 (a) Quacks ... .. 963 (b) Chiropractorsand osteopaths .......... 963 (c) Psychologists....................... 963 Controlling the quality and supply of doctors ... ....... 969 (a) Medical education. .... ............. 970 (b) Licensing of forcign-trained doctors .. ........ .974 C. Determining the Conditions of Practiceand Paynwcnt ....... .. 976 Methods of practice .... , ............ 977 Methods of remunerating the physician. ......... 978 Methods of payment by the consumer................... 90 Methods of controlling disapproved voluntary health insurance plans 93 (a) Discrimination against participatingphysicians . 98 (b) Sponsorship and promotion of competing plans and restricthe legislation ..... ............... 92 (c) The struggle against HIP ..... ........... 994 D. AMA Attitudes toward Health Measures under Government Auspices 997 Governmental lcvel of sponsorship and control ........ 03 Federal grants-in-aidfor health purposes ......... 1001 (a) Grantsfor health scr-ices .... ........... 1 ) (b) Grants for mcdical research .... .......... 1001 (c) Grantsfor hospital construction .... ......... 102 (d) Grants for medical education ..... .......... 1w2 Federalhealth services .................. Im4 (a) United States Public Health Service. ....... 1004 (b) Military and vetcrans' meicine. .... ......... 1005 Compulsory, health insurance .. ............ 1007 (a) Deivelopmcnt of a nationalhealth program. ...... 1007 (b) AMA tactics of opposition.... ........... .1010 V. LriTATioNs o.N AMA Povwm. ..... ............... 101 VI. CONCLUSON .. .......... .................... 1021 THE AMERICAN MEDICAL ASSOCIATION: POWER, PURPOSE, AND POLITICS IN ORGANIZED MEDICINE INTRODUCTION IN its hundred-odd years of existence the American Medical Association has attained a position of undeniable authority and influence over medical affairs. The power of organized medicine affects not only the physician but also everyone who requires the assistance of the healing arts. AMA successes in raising the quality of medical education, practice, and care are beyond question. However, in these endeavors it has acquired such power over both public and practitioner that it can channel the development of American medicine. Dangers inherent in such power are compounded by the layman's ignorance of medical matters and the AMA's monopoly position as spokes- man for the profession. Out of this situation arise questions of grave signi- ficance. The AMA is motivated both by obligations to the public and loyalties to its own members. The demands on it from these two points of view under- lie all its activities and suggest the possibility of conflict. To what extent does professional self-restraint, combined with present laws and institutions, assure that this conflict will be resolved in favor of the public interest? TEm AMA STRUCTURE Membership The American Medical Association consists of 53 state and territorial (con- stituent) societies and 1987 county (component) societies.1 Each county society sets its own qualifications for membership and its members automatically belong to the state association.2 Aside from racial barriers in most southern counties, 3 all "reputable and ethical" licensed M.D.'s are eligible for 1. AMA, GuiDE To SERviczs 4 (1952). Each component society serves a separate geographical area, and there can be no more than one county society in such an area. E.g., VA. MED. Soc BY-LAWs Art. 3, § 2 (1953). However in some rural areas a local society may cover several counties. E.g., COLO. STATE MED. Soc. BY-LAWS c. 11, § 1 (1951-52). 2. E.g., id. c. 11, § 5. Some county societies in Kansas admit "associate members" although the state society will not recognize them as members. REPLY TO QUESTIONNAIRE, KANSAS MEDICAL SOCIETY, Question No. 10. (Hereinafter cited as QuESTIONNAIRE No. -. A comprehensive questionnaire was sent to the 48 state medical societies and to the Medical Society of the District of Columbia. The following twenty-four fairly representative societies responded in varying degrees of detail to the 83 questions: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Illinois, Iowa, Kansas, Louisiana, Maine, Massachusetts, Missouri, Montana, New Hampshire, New Mexico, Pennsylvania, South Dakota, Texas, Utah, Vermont, Virginia, Washington, and West Virginia. The original answers from each society and a compilation of all the answers given to each question are on file in the Yale Law Library.) 3. See note 22 infra. 19541 THE AMERICAN MEDICAL ASSOCIATION membership.4 And in most areas virtually every practicing physician belongs to his local society.5 Until recently, all members of county and state medical societies were also automatically members of the national association. But in 1950 payment of dues, previously assessed only by the county and state groups, became a prerequisite to AMIA membership.0 Now some physicians belong only to their county and state societies, and are not members of the American Medical Association.7 On the other hand, since belonging to a county society is a prerequisite to admission at all levels, membership in the AMA depends upon acceptance by the local organization. Reasons for meembership. Many factors contribute to the high percentage of physician membership in organized medicine-a proportion unique among voluntary professional associations.83 With membership in the society, the doctor receives ready access to the social and professional contacts indis- pensable to the growth of his practice-contacts which may lead to patient referrals and consultations.9 Additionally, there is the all-important factor of association with men engaged in his own science, with opportunities for ex- change of knowledge and acquisition of professional status. The medical societies disseminate the latest scientific information through professional journals which are available to members either at no cost or at reduced rates, and through lectures, exhibits, and medical libraries which the societies sup- port. In addition to these professional services, the local and state societies aid members by providing group malpractice insurance,10 and by offering legal advice.11 Many of the larger societies maintain bill collection agencies.'- 4. Many county societies impose additional requirements upon applicants for membership: e.g., they must be graduates of an AMA approved medical school, United States citizens, present medical practitioners within the county, and practitioners of non-sectarian medicine. QuEsTIONNAIm No. 9. 5. QuEsTIoNNAiE No. 5. Half of the societies report over 90S membership among eligible, active physicians in their states. Only two states-Pennsylvania and Washing- ton-report two-thirds membership or less. 6. See text at note 656 infra. 7. The AMA claims a membership of over 140,000. IT's Youa AMA [1] (1953). Although in one society-New Hampshire-less than E0,% of the state society members pay dues to the AMA, more typically 95% to 99% are AMA members. Qvrsnon:;-,%rx No. And in Illinois, the Society's constitution and by-laws require all members to pay AMA dues. ILLuIzOs QUEsTIONNAImE No. S. S. How the Doctors Solved the CoordinationProblem, 21 A.B.A.J. 221, 233 (1935). 9. See Group Health Cooperative of Puget Sound v. King County Medical Society, 39 Wash.2d 586, 626, 237 P2d 737, 759 (1951); G.-,rcFxu, Tnn PvarLc.um LiFE or cnu Azmmc.xAN MiEDIc.cL AssociATioz 103 (1941) (hereinafter cited as G.,trx:a=). 10. A 1950 survey showed 35% of the county societies maintaining grcqup malpractice insurance for their members. AMA, AcriviTiEs OF Couv, .MEDICAL SOMciIES 6, 7 (1951). Three state societies reporting now offer this insurance to their members and tuo others formerly did so. QUEsTIO NNAx No. 55. 11. See, e.g., You AND THE MEDICAL SOCIETY OF THE STATE OF NEW Yonn 14 (1952) (legal defense provided for members involved in malpractice suits). 12. Seven percent of the county societies respunding to an AMA questiknnaire hbd collection bureaus for their members. AMA, AcriviTiEs o rC.ux MEDICAL ScL.ez,;i, 6, 7 (1951). THE YALE LAW JOURNAL [Vol, 63: 937 There may also be direct economic benefits incident to membership. Since the societies often contract to furnish medical care to indigents

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