If you wanted to know what doctors thought about money and medical practice, including plumber envy, you’d read American Medical News(AMN). That’s the biweekly newspaper the American Medical Association just announced it’s shutting down.
Unlike JAMA, in which doctors appear as white-coated scientists, AMN focused on practical and political issues, not least of which was the bottom line. For outsiders, that’s provided a fascinating window into the House of Medicine.
Take, for instance, the sensitive topic of plumber envy. A 1955 AMA report I discovered during research on a book I wrote some years ago lamented physicians’ “consistent preoccupation with their economic insecurity,” including envious comparisons to “what plumbers make for house calls.”
Flash forward to 1967. Thanks to most patients now enjoying private or public health insurance, doctors’ incomes have improved substantially. The pages of AMN include advertisements for Cadillacs and convention hotels (Miami Beach is “Vacationland USA”). However, one man’s income is another man’s expenses, and complaints about rising medical costs have surged. When AFL-CIO president George Meany joins the chorus of carping, an AMN headline asks, “How about plumbing?”
If today’s doctors have finally piped down about plumbers – an electronic search of AMN archives back to 2004 produced no plumbing references – it may be because the average plumber earned about $51,830 in 2011, according to the Bureau of Labor Statistics, while the average general internist earned $183,170. Meanwhile, the AMN ads for cars were long ago replaced by ads for drugs, where influencing a doctor’s choice can drive millions or billions in revenue.
Unsurprisingly, the issue of rising medical costs and its causes has been a persistent theme in AMN since its launch in 1958. (For my book research, I pored through its indexes and old issues.) While AMN ran articles with titles like, “Medicine Called ‘Best Bargain Ever,’” the AMA leadership knew health cost unhappiness was not a psychosomatic disorder.
When Medicare and Medicaid took effect on July 1, 1966, medical cost inflation became supercharged. The very first National Conference on Medical Costs was convened in Washington by President Johnson at the end of June, 1967. That’s how little time it took for policymakers to realize costs were out of control. Invited experts were asked “to discuss how to lower the costs of medical services without impairing the quality,” AMN reported.
Was any of this the fault of doctors? Secretary of Health, Education and Welfare (HEW) John W. Gardner warned that “the health professions…must search for new and better and less expensive ways of doing things.” But while AMA officials acknowledged vaguely that doctors needed to become more “efficient,” an AMN editorial criticized Gardner because “two of the major factors – inflation and increased federal government intervention into the financing of health care – were practically ignored.” Left unstated was that this increased intervention included sharply increased federal funding for research, education and building new hospitals, as well as a Medicare system that let doctors set “usual, customary and reasonable” fees.
In the July 21, 1969 issue of AMN you could find the very first use of the term, “crisis” by a president referring to health care costs. Starting a tradition his successors would all follow, President Richard Nixon declared the rising cost of health care “a major crisis” and vowed to “reshape the system” to keep costs down.
That same issue covered medico-political controversies unlikely to show up in JAMA. Protesters disrupted the annual AMA House of Delegates meeting by booing a Marine Corps color guard, after which a New York psychiatrist went on a “diatribe” whose particulars AMN faithfully recorded. The psychiatrist charged that “the AMA is a conspiracy against health, a menace to the nation’s health, maintains the ‘largest and richest lobby’ in Washington, D.C., fights against low-cost, high quality health programs and ‘created’ the health manpower shortage.” The shrink then pulled out his AMA membership card and burned it.
Tellingly, the protest story went into detail about protesters’ grievances. The AMA might have owned AMN, but it practiced real journalism. In fact, its journalism was so real throughout the health reform battles of the 1980s and 1990s that in 1997 the AMA replaced the newspaper’s long-time editor with the communications chief of the hard-right Texas Medical Association. Reporting changes soon followed.
Interestingly, there was one other page one story of that same AMN issue that reverberates in our time. It’s coverage of a speech by outgoing AMA president Dwight L. Wilbur. Take away a few details, and it sounds very much like a flat-out endorsement of the Affordable Care Act.
Wilbur praises the expansion of neighborhood health centers as “a major advance in improving the medical care delivery system;” the ACA gives greater emphasis to Federally Qualified Health Centers. Voluntary health insurance “must cover continuing care in and out of hospitals and catastrophic illness,” asserts Wilbur; the ACA eliminates lifetime limits on health insurance and, through provisions such as Medicare’s accountable care organizations, tries to reward coordinated inpatient and outpatient care.
Finally, Wilbur says that for Americans unable to pay for insurance, “the federal government must provide for a payment of the premium through a mechanism such as the tax credit plan proposed by the American Medical Association.” The most effective means of meeting the rising costs of medical care, he continues, “is to spread the costs as widely as possible through private insurance plans.” Tax credits, of course, are a central part of the ACA’s health coverage mandate affecting employers and individual citizens. (Nixon endorsed the employer mandate, too.) That mandate, in turn, represents precisely the kind of expansion of the risk pool described by Wilbur.
Forget the Heritage Foundation circa 1989. This “ode to Obamacare” by the AMA goes back two decades earlier.
Of course, the AMA proposal was actually meant to derail the “socialized medicine” bugaboo of that time, the single payer system proposed by Congressional Democrats. Troll the pages of AMN long enough and it becomes clear that what the AMA has done for most of the modern era is oppose: oppose expansion of Medicare under President Johnson, wage and price controls under President Nixon, expanded peer review under President Ford, hospital price controls under President Carter, hospital payment reform under President Reagan, expenditure targets under the first President Bush and so on. The only consistent government intervention the group has supported is (surprise) legislation limiting malpractice lawsuits.
Yet as AMN comes to an end, so does the AMA’s era of “just say no.” In May, the AMA told a House committee it would support a gradual phase out of fee-for-service reimbursement in order to rid Medicare of the hated sustainable growth rate (SGR) payment formula. Unfortunately, news of this extraordinary concession was clouded in AMN rather than being subject to journalistic clarity. The AMA, it said, “has called for a variety of payment models to accommodate the diverse range of physician practices.”
AMN was finally done in by its drug habit: pharma company consolidation and the absence of “blockbuster” medications led to a chronic wasting disorder eating away advertising. AMN will expire before fee-for-service payment does. The newspaper made its debut in September, 1958. The last issue will be dated Sept. 9, 2013.
Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, IL; the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management; and a board member of the Society for Participatory Medicine. This post originally appeared at Forbes.