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Excerpt 'From Seeking the Cure: A History of Medicine in America'

by Ira Rutkow, AARP Bulletin, August 12, 2010

The Battle Over Medicare

In June 1965, with Medicare on the verge of passage, the American Medical Association had its annual convention in New York City. Twenty-five thousand organization members descended on the vast Coliseum at Columbus Circle (now site of the Time Warner Center) to take part in the five-day gathering. To the lay observer it appeared to be an impressive show of strength and unity for organized medicine.

The four-story drug and medical equipment exhibit area resembled a “supermarket of medical products.” Attendees strolled around it carrying “shopping bags crammed with pamphlets, boxes and bars of soap, weight-reducing tablets and assorted pills, tubes and bottles,” according to the New York Times. Salesmen stood in colorful booths and hawked items with titles like “Help Build Up Run-Down Patients” and “Hear New Facts About the Night Eating Syndrome.” At one display, a male model lay on a hospital bed, comfortably reading a copy of Playboy, to promote a new product designed to eliminate bedsores.

Doctors gathered in side rooms where they listened to hundreds of scholarly presentations and discussed topics ranging from the latest advances in medicine to the latest advances in quackery. In one panel, the medical director of the Food and Drug Administration gave a lecture on the addictive properties of newly discovered drugs like amphetamines and barbiturates, warning of illegal sales by “vice and crime syndicates.” In another colloquium, a psychiatrist worried that an evil, Svengali-like individual would attempt to hypnotize the public en masse through television. He assured attendees that there was a “compelling need” to institute “stringent safeguards and control” over personnel in the broadcast industry.

Among the most serious problems was tension over racial integration within the profession. A daily picket line of 150 physicians marched at the Coliseum to protest the association’s southern affiliates’ discriminatory policies against African American doctors. An AMA spokesperson unconvincingly explained at a press conference that the organization had urged its member societies “to completely get rid of discrimination,” but in view of existing civil rights laws, it “could not order them to do so.”

But despite everything happening in and around the Coliseum, the real center of activity for the profession was located six blocks south at the recently completed 50-story Americana Hotel (now the Sheraton New York at Seventh Avenue and 53rd Street). Outside the building, 1,000 members of the Congress of Senior Citizens of Greater New York stood chanting, “2-4-6-8, AMA Cooperate—Pass Medicare.” Inside the hotel’s ballroom, the association’s 235-member House of Delegates, its central decision-making body, met in closed session to discuss the impending Medicare threat.

Almost all the delegates opposed the program. “American people have the most serious misgivings about welfare statism,” an Iowa surgeon told journalists in explanation of his viewpoint. While some cautious delegates suggested that, given Medicare’s likely passage, conciliation would be wise, the majority of attendees preferred options like a boycott of the government program or a nationwide doctors’ strike. One physician even had the temerity to suggest that “force must be used when reason will not prevail.”

The delegates had a difficult choice to make. They could either accept that the government had outmuscled them, or they could double-down on their opposition and shift from politicking to insurgency. The future of organized medicine hung in the balance, and the leadership looked to one man: James Appel, the AMA’s recently elected president.

Appel’s clinical career made him well suited to lead organized medicine’s outmoded and conservative House of Delegates. After attending the University of Pennsylvania School of Medicine, he had only completed a general internship before joining his father in private practice. The elder Appel then tutored his son in an apprentice-like relationship still common in 1930s rural America. With his father as guide, he mastered surgical and obstetrical skills and other rudiments necessary for a family doctor. His father also passed down the view that family practice was a sacred profession:

“[Family practitioners] and their patients get to know one another as persons, and the rewards are soul-satisfying,” Appel explained. “[They] are infused with the feeling of devotion and humanism.” From 1933 until a month before his death in 1981, [the younger] Appel practiced in the same house in Lancaster, Pa., where he was born. It is no surprise, perhaps, that a journalist once described the lanky, balding, soft-spoken doctor as “homespun.”

Like many general practitioners, Appel felt that his career needed to be defended from the threats of modern medicine and the federal government, and he became involved in local medical politics at a young age. He spent years working his way through the ranks of his county and state medical societies, and in 1962 the AMA appointed him vice chairman of its board of trustees. He ascended to the presidency three years later. As president, he called Medicare’s congressional supporters a “flock of misled ‘political sheep,’ ” who ignored the wishes of their constituents and listened only to the “sweet voices of the labor leaders and the ivory towers.”

Despite his strong views on the importance of organized medicine, Appel preferred pragmatism to polemics and conciliation to conflict. At the New York City convention, he discouraged physicians from pursuing “unethical tactic[s] ... such as strike or sabotage.” While he resolutely opposed the concept of Medicare, he acknowledged that the legislation had already cleared the House of Representatives and its passage in the Senate was a foregone conclusion. He urged his peers to remember that “[s]ociety depends for its orderly existence upon law. Regardless of our personal opinion, we do not have the right—either as physicians or citizens—to violate a law, or to violate the spirit of the law or its intent. ... We must make every effort to develop [Medicare’s] good points, while working equally hard to eliminate its bad points.”

Appel’s pacifying rhetoric had little effect on the more ardent of his constituents. Doctors accused him of asking them to “walk like zombies or sheep into involuntary servitude” while the federal government extended “fascist control” over hospitals and medicine. Others sent telegrams to their fellow delegates: “Impeach Appel!”

Going into the final day of the AMA convention, Appel did not know if his pleas would be enough to stave off insurrection. He put the issue of Medicare to a vote in the House of Delegates, while cries of “appeasement” and “surrender” echoed in the ballroom. The options were few, strike or support. The delegates sided with Appel, at least in the interim, and decided to postpone any direct strike action until the Medicare bill became law. They instead requested that Appel and other AMA leaders arrange a final face-to-face meeting with President Lyndon Johnson to discuss the status of Medicare.

In the end, it didn’t matter. An unproductive medical summit took place on July 29, 1965. The following day, Johnson flew to Independence, Mo., to sign the Medicare bill in the presence of former president Harry Truman. The federal government had finally triumphed over organized medicine.

After Medicare’s enactment, the AMA’s House of Delegates called a special session. Attendees griped about Appel and the board of trustees’ capitulation to outside forces. Talk of a Medicare boycott reached a crescendo. Appel took the podium and calmly suggested that any action resembling a strike was “foolish and petulant.” He told the audience that they had done their best to defeat Medicare and failed. “We now are expected by the public, the press and the Congress to act as reasonable and mature men and women.” An association lawyer seconded Appel. He cautioned that an organized boycott would create anticompetition problems and expose any participating physicians to legal penalties under the Sherman Anti-Trust Act, including lengthy jail sentences. Ultimately, the pragmatists prevailed, and the House of Delegates agreed to support Medicare. Organized medicine’s quest to remain the arbiter of the nation’s health had come to a quiet and definitive end.

Despite organized medicine’s official support for Medicare, the early implementation phase was rocky. The AMA tried to prevent expansion of the law, theoretically to protect patients from the constraints of the program. “Doctors seek to set policy and avoid any blame for ‘the harmful effects,’ ” headlined the New York Times in November 1965. The Association of American Physicians and Surgeons, a radical splinter group of the AMA, boasted that 50,000 doctors had independently “searched their consciences” and agreed not to become “collaborationists in the evil scheme of Medicare.”

Over time, however, the medical establishment embraced Medicare. By 1970 most doctors not only accepted the program but considered it a financial pot of gold. Government benefits allowed greater numbers of elderly patients to seek medical care. Since financial considerations had been shifted from the patient to the federal program, doctors were free to provide these patients with fulsome care, especially since Medicare benefits continued to increase throughout the decade.

The passage and successful enactment of Medicare marked a new era in American medicine. The profession was no longer the major decision maker for the nation’s health care policies. The term “organized medicine” became something of an oxymoron. The autonomy and authority that doctors had grown accustomed to was gone forever.

Physicians had become but one component in a complex and unruly system. In 1965 there were almost five other health care workers, each with competing interests, for every doctor. New, politically powerful interest groups arose to lobby for consumers, hospitals, insurance companies, medical equipment manufacturers, and pharmaceutical corporations. The most important economic, political, and social forces shaping the character and organization of medicine would now come from outside of the community of doctors.

Excerpted from Seeking the Cure by Ira Rutkow. Copyright © 2010 Ira Rutkow. Excerpted with permission by Scribner, a Division of Simon & Schuster Inc. Read an interview with Ira Rutkow.