Healing Is Noble. Power Is Practical.
Medicine promises healing, yet the structures around it often prioritize influence, lobbying, and financial power. The American Medical Association, alongside its industry partners, has for more than a century shaped not only medical practice but also the laws that govern it. In 2025, the U.S. pharmaceutical and health products sector has already invested about $226.8M in lobbying. PhRMA has contributed $20.6M, and the AMA has spent $13.4M, following nearly $25M in 2024. These figures reflect only part of the year. In the second quarter alone, the industry spent $105.4M, compared to $121.4M in the first quarter. Since 1998, pharmaceutical and health product companies have outspent every other industry in lobbying, with cumulative totals exceeding $6.36B by mid-2025. In 2024, the sector set a record with $387.5M in lobbying expenditures.
The AMA’s influence began with control over legitimacy itself. In the late nineteenth and early twentieth centuries, it lobbied states to make licensure dependent on graduation from AMA-approved medical schools. This gave the association a decisive role in defining who counted as a physician and which traditions would be excluded. When the Flexner Report of 1910, supported by the AMA and the Carnegie Foundation, called for stricter standards, dozens of schools closed, including those training women and Black physicians. By 1930, the number of medical schools had fallen by nearly half. The result was a smaller, more homogeneous physician workforce, shortages in rural areas, and a loss of diversity in the profession.
The exclusion extended into practice. Until 1968, the AMA tolerated local societies that barred Black doctors from membership. In many states, exclusion from the medical society meant exclusion from hospital privileges, making it impossible for Black physicians to treat patients in mainstream hospitals. Communities of color were forced to rely on underfunded segregated institutions. When the AMA finally acted under civil rights pressure, it acknowledged decades of discrimination but the damage had already been done, leaving deep inequities in trust and access that remain visible in health disparities today.
Gender was another front. The AMA long resisted the role of midwives, framing them as unsafe, while consolidating childbirth within hospitals under physician control. This campaign marginalized women providers and replaced longstanding community practices with physician-dominated, higher-cost models. Later, during the expansion of family planning programs in the 1960s and 1970s, the AMA opposed some provisions that it viewed as government overreach, slowing broader access to contraception and reproductive care.
The AMA’s influence extended into knowledge itself. It owns the Journal of the American Medical Association, one of the most widely read medical publications in the world. For decades, JAMA carried advertising revenue from cigarettes, despite mounting evidence of harm. Later, pharmaceutical advertising became a major source of income. The intertwining of publication and advertising raised persistent questions about bias and selective presentation of evidence. Ghostwritten studies and selective reporting of trial data added to these concerns, shaping what physicians believed to be safe and effective.
In national politics, the AMA fought insurance expansion repeatedly. In 1935, it opposed Roosevelt’s inclusion of health insurance in the Social Security Act. In 1945, it spent $1.5M to defeat Truman’s plan, the largest campaign of its time. In 1961, it orchestrated Operation Coffee Cup, distributing Ronald Reagan’s recorded warning against Medicare. Medicare and Medicaid passed in 1965, but the AMA quickly worked to ensure physician payments remained fee-for-service.
Public health campaigns followed a similar pattern. The AMA accepted cigarette ads in JAMA until 1953, remained slow to confront smoking, and only in 1972 took a strong anti-tobacco stance. In 1986, it called for a federal ban on cigarette advertising. This reversal highlighted how profit and politics had delayed clear health warnings.
Malpractice reform became another domain of power. California’s 1975 Medical Injury Compensation Reform Act capped non-economic damages at $250,000. The AMA promoted it as a model. Texas followed in 2003 with caps of $250,000 for physicians and $250,000 per hospital, up to $750,000 total. Florida’s 2003 constitutional amendment limited attorney fees, backed by the AMA and state societies. These measures stabilized insurance markets but restricted justice for patients, especially the elderly and children whose claims centered on non-economic harm.
Corporate medicine also tested the AMA’s stance. For decades, it opposed physicians being employed by hospitals or insurers, warning that independence would be lost. Yet as managed care spread in the 1980s and 1990s, the AMA adapted, lobbying instead for favorable reimbursement and oversight within these new structures. Today, most physicians are employed by large hospital systems or private equity-backed groups, a corporatization of medicine that the AMA once resisted but ultimately accommodated.
Politics remained central. In 1961, the AMA created its political action committee, AMPAC. Since then, it has spent tens of millions on campaign contributions, ensuring access to lawmakers. While historically favoring Republicans, its giving has shifted toward balance, reflecting a strategy of influence over ideology. The adaptability of its political spending has allowed the AMA to remain powerful regardless of which party holds power in Washington.
Globally, the AMA’s victories reshaped America’s unique trajectory. By blocking universal health insurance when other nations acted, it helped make the United States the only wealthy country without guaranteed coverage. Britain created the National Health Service in 1948, and Canada established single-payer systems in the 1960s. The United States, influenced by AMA opposition, instead doubled down on private insurance. The consequences are still visible in medical debt, rationed insulin, and life expectancy that lags behind peers.
Pharmaceutical advertising magnified these dynamics. After the FDA relaxed rules in 1997, spending grew from $1.2B in 1998 to $2.5B in 2000, $4.8B in 2006, more than $6B in 2016, and over $10B in 2024. The ten most marketed drugs accounted for $3.3B of that total. Studies show that advertising increases prescriptions, with patients requesting drugs they have seen and physicians responding. This intersects directly with the AMA-shaped training of doctors, which emphasized pharmacological intervention, creating a cycle that benefits industry while driving costs.
The consequences are profound. Marketing and payments helped fuel the opioid epidemic, with higher payments linked to higher prescribing and overdose deaths. Vioxx, promoted despite cardiac risks, contributed to an estimated 88,000 to 140,000 excess coronary events before its withdrawal in 2004. Prices for insulin and inhalers remain high, sustained by lobbying campaigns that block reform.
There have been benefits as well. Lobbying helped secure a doubling of the NIH budget between 1998 and 2003, fueling breakthroughs in genetics, oncology, and infectious disease. Antiretroviral therapies transformed HIV from a death sentence to a chronic condition. Cancer immunotherapies reshaped treatment. Vaccines for hepatitis and human papillomavirus saved lives worldwide. Advertising campaigns about depression and cholesterol reduced stigma, encouraged patients to seek care, and led to earlier detection and treatment. Educational standards raised laboratory quality and helped establish the United States as a global leader in biomedical science. Malpractice reforms stabilized insurance markets in some states, preventing physicians in high-risk specialties from leaving practice.
Yet the paradox remains. The same forces that secured lifesaving discoveries delayed universal healthcare. The same advertising that raised awareness drove opioid misuse. The same malpractice reforms that stabilized markets denied justice to injured patients. The same educational standards that raised rigor entrenched inequality.
The ethical costs weigh heavily. Autonomy falters when patients decide based on incomplete or biased evidence. Nonmaleficence is broken when foreseeable harm is tolerated for profit. Justice fails when marginalized groups bear the greatest burden of cost and exclusion. The paradox is that the same structures that advanced innovation and awareness also entrenched mistrust, inequity, and preventable death.
Food for thought:
If power has for more than a century delivered both scientific progress and systemic inequity, what reforms would finally redirect it toward prevention, fairness, and trust?
Could transparency in research, strict limits on marketing, inclusive education, and broader scope-of-practice authority shift the balance, or will the same forces that shaped the past continue to dominate the future of American healthcare?
