The word “doctor” was fluid. It could mean a Harvard-trained physician with exposure to anatomy lectures, a midwife who had delivered hundreds of babies through apprenticeship, or an herbalist trusted by rural families for generations. In immigrant neighborhoods it could mean a healer trained in European or Indigenous traditions.
This diversity reflected both freedom and chaos. Families often had to judge for themselves who to trust. Into this landscape stepped the AMA, which promised order, scientific grounding, and professional authority.
The AMA began by creating professional standards such as ethical codes and guidelines for practice. On paper this looked like a movement to improve care. In practice it was also about exclusion. The association labeled midwives, homeopaths, and eclectic healers as “irregulars.” That label was not neutral. It implied inferiority and danger.
The AMA worked systematically to marginalize these practitioners. Hospitals were pressured to deny admitting privileges to non-AMA physicians. State societies barred membership to certain groups. The Journal of the American Medical Association gave voice to one set of healers while dismissing others. By 1904 the AMA had created its Council on Medical Education, which began rating medical schools and setting the stage for deeper consolidation.
The effect was a narrowing of legitimacy. What had once been a profession with many paths became a closed guild. Women and Black physicians found themselves excluded from medical societies. Midwives were pushed aside.
Example: The Erasure of Midwives
In the late 1800s, midwives attended most births in America, particularly in immigrant neighborhoods and rural areas. Many were African American or immigrant women who had learned through apprenticeship and community tradition. Their care was affordable and culturally trusted.
The AMA, however, portrayed midwives as “unclean” and “dangerous.” In journals and public campaigns they were described as ignorant remnants of an earlier age. Hospitals began closing their doors to them, and states raised licensing standards in ways that excluded them.
By the 1930s the effort had worked. Fewer than 15 percent of births were attended by midwives. In the South, Black families who had relied on “granny midwives” were pushed into segregated hospitals where they often faced discrimination and poorer outcomes.
Example: Black Physicians Pushed Aside
Dr. Daniel Hale Williams, a pioneering Black surgeon, performed one of the first successful open-heart operations in 1893. He also founded Provident Hospital in Chicago, the first Black-owned hospital in the country. Despite his achievements, Williams and other Black physicians were routinely excluded from mainstream institutions.
The AMA did not officially ban Black members, but local and state societies often did. Because AMA membership was tied to hospital privileges, this exclusion cut Black physicians off from research, teaching, and practice opportunities.
When the Flexner Report later closed five of the seven Black medical colleges, the training pipeline nearly vanished. By 1920 Black physicians made up less than 2 percent of the profession, even though Black Americans were almost 10 percent of the population. The result was a health gap that has never been fully repaired.
Example: Women Physicians Shut Out
The Woman’s Medical College of Pennsylvania, founded in 1850, trained thousands of women doctors who proved their skill in medicine and surgery. By the late 19th century, several women’s colleges were producing graduates who competed with their male peers.
The Flexner Report dismissed most of these schools as substandard. Philanthropic donors withdrew funding, and state boards restricted licenses. By 1930 only one women’s college remained open. Women’s representation in medicine fell, reversing decades of progress.
The setback was long-lasting. For nearly half a century, women entered the profession in very small numbers. Leadership in medicine became even more male-dominated, and opportunities to advance were few.
In 1910 the Flexner Report was published. Abraham Flexner, an educator rather than a physician, surveyed medical schools across the United States and Canada. His report was commissioned by the Carnegie Foundation and quickly taken up by Rockefeller philanthropy.
Flexner’s conclusions favored schools with laboratories, teaching hospitals, and research programs. Proprietary schools without those resources were judged as inadequate. Policymakers and philanthropists used the report as a roadmap for reform.
Between 1905 and 1915 more than 40 percent of American medical schools closed. The closures fell hardest on Black colleges, women’s colleges, and alternative institutions. The benefits included higher standards and the end of diploma mills. The cost was the loss of diversity, affordability, and accessibility.
Rockefeller’s General Education Board, founded in 1903, became the main source of money for Flexner’s vision. Between 1913 and 1929 it distributed 94 million dollars to twenty-five elite universities. The funding built laboratories, teaching hospitals, and research centers that cemented their dominance.
This philanthropy was not neutral. Rockefeller’s companies were already moving into chemicals and pharmaceuticals. By supporting laboratory-based medicine, he tied the profession to fields that could yield patents and profit. Healing traditions that could not be commercialized were left outside the system.
The Flexner Report was not only advice. States rewrote their licensing laws to require graduation from AMA-approved schools. Practitioners who had once been legally recognized lost their status.
Licensing boards, staffed by AMA-trained physicians, enforced the new orthodoxy. Authority over who could call themselves a doctor shifted from local communities to a small circle of institutions and associations.
By the mid-20th century the AMA had grown into one of the most powerful lobbies in the country. What had begun as a guild promising standards became an organization dedicated to protecting its own authority and revenue.
In the 1930s, during the Great Depression, President Franklin Roosevelt considered national health insurance as part of the New Deal. The AMA mobilized against it, arguing that government insurance would strip doctors of independence. The proposal died before reaching Congress.
In the 1940s, President Harry Truman tried again with a comprehensive national plan. The AMA launched the most expensive lobbying campaign in U.S. history at the time. They raised millions from physicians, purchased newspaper ads, and warned the public about “socialized medicine.” Truman’s plan collapsed.
As a result, the United States became the only wealthy nation without universal health coverage. The AMA called this a defense of medical freedom. In reality, it was defense of monopoly and financial control.
When Medicare and Medicaid were introduced in 1965, the AMA opposed them as well. Once the programs passed, the AMA worked to influence their structure. Payment was tied to procedures and services rather than health outcomes. This created incentives for intervention, testing, and prescribing. Prevention and counseling were undervalued.
In 1966 the AMA introduced the Current Procedural Terminology (CPT) codes, which standardize billing across the United States. These codes, still owned and managed by the AMA, determine how every service is valued and reimbursed.
This control extends to both private insurers and government programs. Decisions about codes decide whether a counseling session is worth less than a minor surgery, or whether preventive measures will be paid for at all. By controlling this financial language, the AMA shapes priorities across the entire system.
By the late 20th century the AMA had ceased to be a neutral guardian of standards. It had become an industry lobby. It blocked coverage expansions, defended payment systems that rewarded profit, and aligned itself with insurance and pharmaceutical interests.
The corruption lay not only in lobbying but in the use of professional authority to entrench financial gain while excluding approaches that might have expanded access or emphasized prevention.
The transformation of American medicine did raise standards and close unsafe schools. It made education more scientific and consistent. Public trust in physicians rose.
Yet the losses were deep. Black communities lost the schools that had trained their doctors. Women lost their foothold in a profession where they had been gaining ground. Rural and working-class families lost affordable caregivers. Traditions of preventive and community-based care were abandoned, not because they lacked value, but because they lacked profitability.
The history of American medicine is not a distant story. Its legacy lives in the current structure of the health system. Every decision made in the early 20th century continues to shape the way patients experience care today.
Access and representation: When the Flexner reforms closed five of the seven Black medical schools and most of the women’s colleges, the long-term result was a profession dominated by white men from privileged backgrounds. That imbalance is still visible. Black Americans make up nearly 14 percent of the population but only about 5 percent of physicians. Women now enter medical school in greater numbers, but they remain underrepresented in leadership and high-paying specialties. These gaps were the result of deliberate closures and exclusions.
Bias toward procedures and pharmaceuticals: The AMA’s influence over Medicare, Medicaid, and CPT codes cemented a payment model that rewards interventions while undervaluing prevention, counseling, and community health. Today, a brief procedure often pays more than a half-hour spent helping a patient manage diet, exercise, or stress. Pharmaceutical solutions are heavily incentivized because they can be coded, billed, and patented. Preventive approaches, which might reduce long-term costs and suffering, remain chronically underfunded.
Distrust and disparities: The removal of midwives, Black physicians, and women’s colleges weakened trust between the medical system and entire communities. Many Black families were left without doctors who understood their realities. Women patients often found themselves dismissed in male-dominated settings. Communities that had relied on herbalists or midwives saw their traditions criminalized. Today’s health disparities in maternal mortality, chronic disease, and access to culturally competent care are direct descendants of these earlier decisions.
Power concentrated in a few hands: The philanthropic investments of Carnegie and Rockefeller made a small circle of elite universities the permanent centers of American medicine. That concentration remains. Research funding, training pipelines, and medical prestige are still clustered in a narrow group of institutions. What was once built with philanthropic dollars is now reinforced by government policy and insurance structures.
These choices explain why the United States spends more on health care than any other nation but ranks poorly on measures such as life expectancy, maternal mortality, and access to primary care. The system delivers enormous profits to certain sectors while leaving many patients behind.
History matters because it shows that these problems are not simply the product of complexity or chance. They are the outcomes of design. And design can be changed. Recognizing how the system was built opens the possibility of rebuilding it differently.
Food for Thought
Should a professional association control the billing codes that decide how medicine is valued?
If lobbying campaigns block universal coverage, what does that reveal about the priorities of the profession?
How can pathways be rebuilt for Black students, women, and working-class families who were shut out of medicine by design?
What role should philanthropy play in shaping health care today, and how can it serve people rather than industry?
What steps would strengthen a system that heals without exclusion and restores value to prevention and community health?
