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What history can teach us about medical politics today

From the July-August ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

"If an American physician had been asked what were medicine's major dilemmas, he might have replied that there was poor morale in the profession compared with earlier in the century (reflected in the journals and laments over medicine's 'declining state') ... [and] that standards of education and practice were uneven ... "

The quote above from Rosemary Stevens' book "American Medicine and the Public Interest" sounds like an all-too-familiar recitation of the views of American physicians today. In fact, it describes the prevailing sentiment in American medicine prior to the Civil War, more than 150 years ago.

I recently gave a presentation on the history of American medicine and politics at the ACP-ASIM Alaska Chapter meeting. As I researched the topic, I was struck by how many issues debated today echo the controversies and conflicts of the past. I also found that concerns about the "declining state of the medical profession" have been expressed repeatedly in our nation's past. The good news is that the medical profession has always found a way to prosper and grow, no matter how bad things seemed at the time.

Control of professional standards

Today, organized groups of nonphysician health care providers are aggressively challenging licensing laws in many states. Surprisingly, similar debates raged in the 18th and 19th centuries.

In the 1760s, American settlers returning to the colonies after completing medical training in Edinburgh, Scotland, petitioned the Virginia House of Burgesses to restrict the practice of medicine to "those who were licensed and held a doctor's degree." They were unsuccessful, however, "because an elite based on social distinction was bound to fail in this country" (Stevens). By 1830, the political climate had changed. Medical societies existed in most states, and most state legislatures required physicians to meet state licensing standards in order to practice medicine.

By the 1850s, however, many states repealed all medical regulations and licensure requirements, responding to a public backlash against "elitism." As Stevens noted, "Just as England was preparing to entrench medical licensing by Act of Parliament, the U.S. seemed to accept the market as the sole criterion for professional skill."

Not until the 1870s did medical licensure become an established function of the state legislature, under the Medical Practice Acts. This body of law remains the basis for licensure and scope of practice limitations throughout the United States and has been aggressively challenged by nonphysician providers seeking to expand their scope of practice.

Guaranteeing access to care

Early in the 20th century, American medicine, as embodied in the AMA, favored compulsory health insurance coverage. By 1920, however, the AMA had reversed course, opposing compulsory insurance coverage as "un-American." It saw compulsory coverage as a threat to professionalism itself, requiring acceptance of mandatory fee schedules, work reviews and control by organizations outside the doctor-patient relationship. Many physicians today oppose government-mandated coverage for the same reasons.

The AMA later played a key role in blocking the Truman administration's efforts to guarantee coverage for all through a 4% increase in Social Security taxes. But when it came to Medicare, the AMA found that it could no longer frustrate the will of a popular and determined president and Congress.

After Lyndon Johnson and the Democratic Party won an overwhelming victory in the 1964 elections, the Johnson administration made enactment of Medicare a top priority. But it was not just presidential popularity and clout that carried the day. Robert Ball, one of the architects of Medicare, observed that they succeeded when others had failed because they made the pragmatic decisions. They limited Medicare to the elderly, rather than trying to cover everyone, and they worked toward the limited goal of giving the elderly the same access as everyone else, rather than reforming the status quo.

Following the humiliating defeat over Medicare, the AMA also changed. According to an authorized history of the AMA, new leaders who were less inclined to be crusaders took the reins. As Frank D. Campion wrote in "The AMA and U.S. Health Policy Since 1940", "The crusader is always throwing down the gauntlet and offering his adversary a hard choice: fight to the death or unconditionally surrender. But after 1965, a new generation of leaders slowly came to power .... They were not crusaders but pragmatists."

Thirty years later, the Clinton administration learned what happens when idealistic fervor gets in the way of pragmatic politics. In recounting his failure to get Congress to agree to his program for universal coverage, then-President Clinton acknowledged in a 1996 interview that "I tried to do too much, too fast .... I should have reached out to Republicans sooner. I should have been more modest."

Lessons for the future

The historical debate over licensure shows us that Americans are unique in their distrust of "elites." Americans place more faith in the market's ability to sort out the good from the bad than in laws that appear to protect a privileged class from competition. While organized medicine today must continue to advocate for licensing restrictions that protect the public from unqualified practitioners, we will succeed only if we can show a skeptical public that our motives are grounded in a dedication to quality, not preservation of an elite status for physicians.

When you compare the failure to enact universal coverage in the 20th century to the successful enactment of Medicare, it becomes clear that pursuing modest goals that build on the status quo is more likely to succeed than idealistic crusades to re-invent the entire system. This lesson has guided ACP-ASIM's new proposal to expand health coverage in stages over the next seven years, rather than immediately address every problem with the current health care system.

History does not predict the future. While today's issues may be similar to those in the past, they are hardly identical. However, history can provide valuable lessons on how to shape our advocacy agenda so that we have a better chance of succeeding where others have failed.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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