Special Interest Groups

• WHAT IS ITS MISSION?
• HOW IS IT STRUCTURED?
• PRIMARY FUNCTIONS
• PROGRAMS
• BUDGET INFORMATION
• HISTORY
• CURRENT POLITICAL ISSUES
• FUTURE DIRECTIONS
• FAST FACTS
• GROUP RESOURCES
• GROUP PUBLICATIONS
• BIBLIOGRAPHY

ESTABLISHED: May 7, 1847
EMPLOYEES: 1,100 (1997)
MEMBERS: 297,000 (1997)
PAC: American Medical Political Action Committee (AMPAC)

Contact Information:
ADDRESS: 515 N. State St. Chicago, IL 60610
PHONE: (312) 464-5000
FAX: (312) 464-4184
URL: http://www.ama-assn.org
PRESIDENT: Nancy W. Dickey, MD

WHAT IS ITS MISSION?

According to the American Medical Association (AMA), its goal is to "promote the science and art of medicine and the betterment of public health. We serve physicians and their patients by establishing and promoting ethical, educational, and clinical standards for the medical profession and by advocating for the highest principle of all—the integrity of the patient/physician relationship."

The AMA, a federation of 54 state and territorial medical associations and societies, was founded in 1847 and is the largest and oldest national professional organization for physicians in the United States. Its efforts are directed toward furthering the interests of the medical profession and improving the health of the U.S. public. Membership is open to doctors of medicine (M.D.s), doctors of osteopathy (D.O.s), and medical students. In 1997 about 40 percent of the nation's 700,000 physicians and 55 percent of its medical students belonged to the AMA.

HOW IS IT STRUCTURED?

The 54 state and territorial medical associations and societies that make up the AMA (formally known as "constituent associations") represent all 50 states, Guam, Puerto Rico, the Virgin Islands, and the District of Columbia. The constituent associations are composed of several hundred county and district medical societies. Most AMA members buy a combined local, state, and national membership package, although it is possible to join the national AMA directly.

AMA policies are set by the organization's 475-member house of delegates, which meets twice per year. Delegates represent various groups: the constituent associations; 95 national medical specialty societies, such as the American College of Surgeons and the American Psychiatric Association; the surgeon general of the United States and a handful of other federal service agencies; and the AMA's six "special sections" representing the interests of medical residents, medical schools, medical students, hospital and clinic physicians, young physicians, and graduates of foreign medical schools.

The board of trustees is an 18-member body charged with handling the general business of the organization and implementing the policies of the house of delegates. The board also serves as the public face of the AMA; its members often deliver the AMA message to medical and nonmedical organizations, government bodies, and the media. Board trustees are elected by the house of delegates with the exception of a medical-student trustee who is elected by the Medical Student Section Assembly. The trustees include a president-elect, a president, and an immediate past president, each of whom holds office for one year before rotating into the next position. All other trustees serve four-year terms, except for two elected to represent medical students and medical residents, who hold office for a shorter period. Board officers include a chair, a vice chair, a secretary-treasurer, and three members who act as an executive committee. Day-to-day management of AMA affairs, however, is the job of a board-appointed executive vice president.

AMA policy is guided, in part, by seven advisory bodies: the Council on Constitution and Bylaws, the Council on Medical Education, the Council on Medical Service, the Council on Ethical and Judicial Affairs, the Council on Long Range Planning and Development, the Council on Legislation, and the Council on Scientific Affairs. A special position is occupied by the nine-member Council on Ethical and Judicial Affairs (CEJA) which, among other things, is responsible for interpreting the AMA's code of ethics, a document that dates back to the AMA's foundation in 1847 and lies at the heart of the AMA's identity as an organization. The CEJA investigates ethical issues as a result of its own initiative or through resolutions by the house of delegates or public complaints about improper medical behavior.

The AMA has three affiliates, all headquartered in Chicago. The American Medical Association Alliance, Inc., founded in 1922 as the Woman's Auxiliary, is an organization of more than 60,000 spouses of AMA members who, through more than 800 local chapters, seek to improve public health. The Accreditation Council for Graduate Medical Education evaluates and certifies medical residency programs in the United States. There is also an Accreditation Council for Continuing Medical Education.

PRIMARY FUNCTIONS

As a professional association, the AMA works to further the interests of its members; as a preeminent health care organization, it also has the goal of improving and ensuring the public's health. The AMA's work includes maintaining a code of medical ethics for its members; setting standards for and helping to finance medical education; producing the Journal of the American Medical Association and other publications; sponsoring a political action committee (AMPAC) and lobbying Congress for legislative changes favorable to the medical profession; campaigning against smoking and for other improvements in public health; and making medical information available to the public through the Internet and other media.

The AMA also maintains special-interest groups for medical students, minority physicians, and others. It sponsors practice-related initiatives such as the Doctors Advisory Network, which puts AMA members needing business advice in touch with the appropriate professionals, and Project USA, a program which recruits primary care physicians to serve as short-term volunteer replacements for U.S. Public Health Service physicians in rural areas. The focus of AMA activity is the organization's Chicago headquarters. Lobbying and federal government relations are conducted out of a Washington, D.C., office. Smaller offices in New York and New Jersey look after advertising sales for AMA publications.

The AMA in Washington

AMA Washington staffers monitor federal and state legislation and regulations, work with the Council on Legislation and other AMA bodies to develop new legislative initiatives, testify before Congress, meet with government officials, and engage in other activities intended to further the AMA's political policies.

The AMA's political efforts are spearheaded by AMPAC, which was established in 1961. AMPAC has two main goals: to provide financial and other aid to members of Congress who support AMA positions, and to educate and mobilize physicians and their spouses for participation in the political process. AMPAC's 10-member board (which includes a seat for a physician spouse) is appointed by the AMA's board of trustees from nominations submitted by various AMA groups.

The AMA's Division of Political and Legislative Grassroots works with AMPAC to mobilize a force of more than 100,000 politically committed AMA members. Seminars and workshops on political issues and tactics are offered throughout the United States. The AMA Political Grassroots Conference, held every second year in Washington, is attended by several hundred AMA activists and features leading Republicans and Democrats as speakers. The AMA has been at the forefront to use the Internet and other communications advances for political purposes. For example, the AMA sends "Blast Faxes" and E-mail alerts to inform members about perceived legislative threats and has a toll-free telephone hot line system that automatically transfers members' calls to an appropriate congressional member.

PROGRAMS

The AMA's interests are reflected in the many programs and initiatives it sponsors. For instance, in 1997 the AMA founded an Ethics Institute to investigate the ethical implications of genetic research, care for the dying, and other issues; created a National Patient Safety Foundation to find ways to reduce mistakes in medical practice; developed a joint initiative with NASA to examine the health effects of spaceflight; and worked with universities to develop programs to reduce binge drinking by students. Two of the AMA's campaigns have been especially ambitious: its antismoking efforts since the 1970s, and its creation and promotion of the American Medical Accreditation Program (AMAP) in 1997–98.

The AMA founded AMAP in 1997 to provide a universally recognized process for evaluating physicians' credentials and performance. When physicians join a hospital or health plan, they must undergo periodic performance reviews to ensure that their medical care meets the organization's standards. The problem for physicians is that they are usually affiliated with several hospitals and health plans at once, each of which has its own performance standards and review procedures. AMAP's goal is to reduce the costly and time-consuming burden of multiple performance reviews on physicians and the U.S. health care system in general by replacing the thousands of privately run accreditation programs with a voluntary, nationwide program under AMA auspices. In developing and promoting AMAP, the AMA has enlisted the cooperation of national health and regulatory agencies, state medical associations and societies, hospital systems, insurance companies, employers' coalitions, consumer groups, and other organizations with an interest in how medical care is delivered. AMAP's success in instituting this national initiative is far from certain, however, for it still faces two major challenges: convincing thousands of U.S. hospitals and health plans to abandon their tried-and-true accreditation procedures in favor of AMAP's, and certifying 700,000 U.S. physicians.

BUDGET INFORMATION

In 1996 the AMA reported operating revenues of $220.7 million. Membership dues accounted for 31.5 percent of operating revenues, down from 35.8 percent in 1995.

HISTORY

During the 1840s, when the idea for a national medical organization first arose in the United States, a small number of university-trained physicians competed for patients with homeopaths, herbalists, midwives, and other healers who had learned their craft outside the traditional university system. Nationwide medical education standards did not exist and legislative restrictions on who could practice medicine were few and ineffective. In the eyes of medical scholar Nathaniel Chapman, the AMA's first president, the U.S. medical profession was flooded with inferior practitioners, and urgently in need of reform. The concerns expressed by Chapman and other critics prompted 268 physicians from 22 states to meet in Philadelphia, Pennsylvania, in May 1847 to establish the AMA as the national organization for traditionally educated physicians. At that first meeting, delegates adopted a code of ethics that raised the standards of practice at that time. They also passed resolutions for improving medical education and appointed a committee to promote that effort.

Despite its promising start, however, the AMA languished for more than 50 years and by 1900 only 8,000 physicians belonged to the association. During the first decade of the twentieth century, the AMA settled its differences with the homeopaths and other opponents and reformed its organizational structure. As a result, by 1910 it had 70,000 members—half of all U.S. physicians. A decade later, it represented 60 percent of the profession. In 1904 the AMA formed a Council on Medical Education to weed out substandard medical schools and within the space of just a decade or so managed to convince state licensing boards to certify only those physicians who were graduates of council-approved schools. Since the 1940s undergraduate medical programs have been accredited by the Liaison Committee on Medical Education, a joint effort of the AMA and the Association of American Medical Colleges.

The early part of the twentieth century also witnessed the beginning of the AMA's long-standing opposition to government-sponsored health insurance plans and other efforts viewed as limiting physicians' economic freedom. In 1943 the AMA opened its Washington office and formed a Council on Medical Service and Public Relations to fight Congress's Wagner-Murray-Dingell bill, which sought to provide medical and hospital insurance for every family receiving Social Security, and would have required physicians treating such patients to adhere to a fee schedule. A few years later the AMA opposed President Harry Truman's goal of comprehensive national health insurance, as well as efforts by Presidents John F. Kennedy and Lyndon Johnson that led to the passage of Medicare (the national health insurance program for the elderly) in 1965.

After its defeat on Medicare, however, the AMA developed a more pragmatic approach to the issue of health care reform. In 1991 it unveiled Health Access America, a policy supporting universal access to health care through mandatory workplace coverage and enlargement of the scope of Medicare and Medicaid (the national health insurance program for the poor). When Bill Clinton became president in 1992, Health Access America formed the basis of the AMA's reply to President Clinton's ultimately unsuccessful crusade for comprehensive health care reform and a national health insurance plan. Rather than totally rejecting the president's Health Security Act of 1993, as it might have done in the past, the AMA carefully detailed which Clinton proposals were acceptable and which were not, and energetically promoted its own policies for reform.

In the 1990s the AMA had to cope with a steep decline in membership. In the 1960s about 90 percent of U.S. physicians in private practice had been AMA members, but by 1987 only about 50 percent of U.S. physicians belonged to the AMA, and that number dropped to about 40 percent over the following decade. One widely acknowledged reason for the decline was the AMA's refusal to consider alternatives to the traditional fee-forservice approach to compensating physicians. Under this system a physician receives a fee from the patient or the patient's insurer for each service he or she provides, rather than, say, a yearly lump sum from a government insurance plan for each patient in the physician's practice. Many physicians—particularly younger ones—saw the AMA's vigorous defense of the economic status quo as contributing to a national crisis in health care.

Another possible reason for the decline was the AMA's perceived ambivalence toward the large numbers of physicians who had come to the United States from other countries since the 1960s and 1970s. Despite the AMA's attempts to meet the needs of foreign-trained physicians by, for instance, establishing a special section for them in 1996, some detractors still viewed the AMA as hostile or indifferent to their concerns. This may explain why physicians educated outside the United States, who accounted for almost 25 percent of the nation's practitioners in 1997, made up a small proportion of the AMA's membership. The AMA was also less than successful in bringing African American and female physicians into its ranks.

Finally, the AMA's role as a consensus-building institution within the medical profession was being eroded by the rise of health maintenance organizations (HMOs) and other corporate arrangements for the delivery of medical services that were fragmenting a profession that had formerly enjoyed a shared economic identity based on single-physician and small-group medical practices. By the late 1990s the fact remained, however, that in terms of membership numbers, financial power, and political influence, the AMA still eclipsed all other U.S. professional medical organizations.

CURRENT POLITICAL ISSUES

The AMA seeks to influence government policies on a wide range of public health issues. Its vigorous 25-year campaign against the tobacco industry is a case in point. Family violence, children's television programming, and AIDS testing in the prison system are a few of the other issues that the AMA has turned its attention to in recent years. The AMA also intervenes in lawsuits that affect the interests of the medical profession, some of which have broader public policy implications. In 1996 for instance, the AMA submitted an amicus curiae (friend of the court) brief to the U.S. Supreme Court opposing physician-assisted suicide.

As a political force, the AMA has always shown a willingness to tackle big issues and take on powerful opponents such as the tobacco industry, but only in 1997 did it become embroiled in what is perhaps the most emotional topic in contemporary U.S. political life—abortion.

Case Study: The Partial-Birth Abortion Debate

In 1973 the U.S. Supreme Court issued its famous decision in Roe v. Wade, which declared that a woman has a constitutionally protected right to terminate her pregnancy under certain circumstances. Shortly after, the AMA's house of delegates adopted a resolution stating that abortion is a medical procedure properly carried out only by licensed physicians, but that the decision to perform abortions is a matter of conscience for each physician. After 1973 the AMA supplemented its general policy on abortion with stands on particular issues, such as the availability of the abortion pill RU-486, but for almost 25 years avoided involvement in legislative debates over abortion. The issue that drew the AMA into the abortion conflict in 1997 was the use of a procedure known among physicians as intact dilatation and extraction and popularly referred to as partial-birth abortion.

Because a partial-birth abortion is sometimes performed when a fetus is 20 weeks or older, some opponents of abortion view the procedure as infanticide. Even some pro-choice are bothered by the fact that the procedure is done with fetuses whose physiological development is well underway. Congress first entered the controversy over partial-birth abortion in 1995, when a Republican-sponsored bill to outlaw the procedure passed the House and the Senate but was vetoed by President Clinton in April 1996. An attempt to override the veto failed.

At the December 1996 meeting of the AMA's house of delegates, members were asked to vote on a resolution supporting the criminalization of partial-birth abortion. Instead, they adopted a resolution reaffirming the AMA's existing abortion policy and sent the issue to the board of trustees for further study. The committee submitting the alternative resolution indicated that its recommendations were based on a core tenet of AMA ideology, "the belief that governmental interference into the practice of medicine is inappropriate and ultimately harmful to the patient." A few months later, in mid-May 1997, the AMA confirmed that it did "not support any [abortion] legislative proposals at this time." Yet just a few days later, on May 19, the AMA unexpectedly reversed its position. AMA Executive Vice President P. John Seward sent a letter on behalf of the board of trustees to Republican Senator Rick Santorum, who had recently introduced a bill outlawing partial-birth abortion, stating that the AMA supported Santorum's bill on the basis that partial-birth abortion is "a procedure we all agree is not good medicine."

The unexpectedness and timing of the AMA's action raised suspicions about the organization's motives among pro-choice activists and within the medical profession itself. Timing was an issue because May 19 was also the day that Seward sent 125 congressional leaders an eight-page list of requests concerning upcoming negotiations over Medicare budget cuts that threatened to harm the medical profession's economic position. Kate Michelman, president of the National Abortion and Reproductive Rights Action League, was quoted by Helen Dewar and Judith Havemann in the Washington Post as saying that she felt the AMA was attempting to protect physicians's wallets and that "the AMA cares much more about moving their political agenda through a Republican-controlled anti-choice Congress than they do about women's health and women's rights." Both the AMA and Santorum, however, dismissed such claims.

Santorum's bill was approved by the Senate on May 20 and sent to the House for its consideration. In the meantime, controversy continued to build within the AMA over the board of trustees' endorsement. Groups such as the American College of Obstetricians and Gynecologists, and some state medical associations, resented the fact that the board had made such a momentous decision without gaining the support of the house of delegates. Another concern was that the bill, by setting limits on a particular medical procedure, opened the door to widespread government interference in medical decision making. The controversy came to a head at the house of delegates meeting that June, where, after five hours' debate, the members finally voted to support the board's actions.

A June 1997 Washington Post article by Abigail Trafford offered a possible explanation for the AMA's decision. AMA's president-elect Nancy W. Dickey observed that since 1995 many states had attempted to pass their own laws against partial-birth abortion, some of which were more strongly worded than the federal bill. The AMA board therefore made a strategic decision to support the federal bill as a way of short circuiting the more restrictive state bills. As Dickey said, "In an ideal world, there would have been no legislation. That was our preference. Unfortunately, it's not an ideal world." Dickey's revelation that the board would have preferred not to support the bill was in keeping with the AMA's traditional aversion to government interference in medical decision making, but her comments undercut Seward, her organization's executive vice president, who only a month before had told the New York Times that the AMA supported the federal bill on ethical grounds. Despite the reasoning behind the AMA's decision, the partial-birth abortion bill was quickly vetoed by President Clinton after being approved by the House in October 1997.

FUTURE DIRECTIONS

A pressing problem that the AMA faces is to find a way to reverse the AMA's declining membership. While the percentage of U.S. physicians belonging to the AMA has been falling since the 1960s, the AMA's efforts as a public health advocate have grown more ambitious and costly. A smaller membership base means less revenue to finance the organization's initiatives. At the December 1997 meeting of the house of delegates, according to Mary Chris Jaklevic, writing in Modern Healthcare, "declining membership . . . became a rallying cry for nearly every topic on the agenda."

GROUP RESOURCES

A good starting point for information on the AMA is its Web site at http://www.ama-assn.org, which provides, in addition to press releases and descriptions of various AMA activities, a downloadable "PolicyFinder" file that includes a searchable database of the organization's constitution and bylaws, the policies of its house of delegates, and the formal opinions of its Council on Ethical and Judicial Affairs. Although much of the Web site is geared toward physicians and medical students, it also offers an impressive collection of health and fitness resources for consumers, including "AMA Physician Select," a geographically organized database containing information on nearly every MD and DO in the United States.

GROUP PUBLICATIONS

The weekly Journal of the American Medical Association (JAMA), widely considered one of the world's leading medical journals, contains reports of original research as well as articles on ethical, social, and political issues affecting the medical profession. JAMA, which can be found in some public libraries, is distributed to every member of the AMA, as is another weekly, the American Medical News, a newspaper that concentrates on political, professional, and business matters. The AMA also publishes nine specialized medical journals, available by subscription, and books for physicians and medical students. Since the early 1980s the organization has also promoted a line of well-received consumer publications such as The American Medical Association Family Medical Guide and the American Medical Association Complete Guide to Women's Health, both published by Random House.