When doctors form professional associations, their aim is to advance the profession and improve health. They do this by providing services, such as continuing medical education and career connections. In addition, they advocate for specific health issues and promote policies that benefit patients and society at large. They may also lead social changes—as long as these processes do not challenge the neoliberal order or threaten their place within it. Like other trade unions, medical associations are supposed to be democratic entities able to represent the diverse desires and agendas of their members. However, many scholars believe that doctors’ associations have been systematically captured by powerful outside forces.

The American Medical Association’s decline is a case in point. When it was founded in the eighteen-forties, its main concern was to raise professional standards. At the time, Princeton sociologist Paul Starr writes, medical schools proliferated, regardless of their quality; a year of course work might contain just three or four months of learning. The AMA’s early efforts to regulate medical school curriculum and licensing helped slow the expansion of unqualified physicians, while the association’s growing political influence, combined with new perks such as malpractice insurance coverage, drove membership.

But as the world changed in the sixties and seventies, so did the AMA. Feminism and Title IX opened medicine to women, whose numbers grew from nine per cent in 1970 to more than twenty-five per cent by the end of the decade. Civil rights and immigration legislation removed racial barriers, resulting in the influx of people of color into the ranks of American physicians. The AMA shifted its priorities accordingly, but its sway waned as state and specialty medical societies accumulated more political clout and splintered its dues revenue.

Today, the AMA has lost more than half of its members over the past two decades. Its membership now stands at about 130 000, and its governing body, the House of Delegates, is often divided over policy.

The AMA’s decline has been exacerbated by its own policies. Its political lobbying budget has shrunk as more members join state and specialty groups that offer perks such as discounted continuing medical education programs, reduced costs for malpractice insurance, and discounts on the acquisition and start-up of private practices. In addition, more and more states have passed laws allowing medical associations to endorse specific health care plans and vote on the issue of physician reimbursement.

Many physicians, however, remain convinced that their national medical associations provide valuable services and should continue to exist. They argue that a single, unified voice at the federal level is more important than the many voices of individual state and specialty groups.