Despite Thursday's history-making endorsement of U.S. health-care reform by the American Medical Association, which has opposed comprehensive changes since tires were made of iron, the tradition of politics-as-usual still holds the most sway, an economist and health-care historian says.

"Over time, health-care reform in this country has been defined by the politics of incrementalism," said Melissa Thomasson, a Miami (of Ohio) University professor and leading expert on the machinations of health care, American style.

"We cover little groups at a time and are happy to do so, as long as it doesn't really affect mainstream Americans or violate the interests of interest groups," Thomasson said in response to a set of e-mail questions from the Deseret News.

In the 1960s, when a significant number of Americans — the poor and elderly mostly — couldn't get or afford insurance like some 45 million today, "voil? Medicare and Medicaid," she said. "That happened only because private insurance companies were not threatened; they couldn't pay for it anyway," she said. "Doctors could earn more money and middle-class Americans didn't see it as draining their wallet with no benefit. Later, we found lots of kids could not get Medicaid. Voil? the Children's Health Insurance Program."

Whenever any group has been threatened by reform, they protested loudly, she said, adding that the AMA has fiercely fought against government-provided health insurance.

"The incredible strength of their opposition over time could explain the failure of reform in the past," she said, especially during the Truman era, when an AMA brochure on compulsory or voluntary insurance declared that "the people's decision will determine the ultimate fate of freedom and truth in this nation."

Thursday's endorsement now begs the question: Will the AMA's support explain reform's success, if it passes, this time around?

"They have always made sure, and even did this when they set up the Blue Shield plans in the 1930s, to not let government and insurance companies determine their incomes," Thomasson said, adding that when Medicare was first enacted, physicians were reimbursed on a cost-plus basis — physicians told government their fees, and the government reimbursed them. "It was incredibly inflationary."

The tenets of health-care reform on the AMA Web site are:

Health-insurance coverage for all Americans. That means more paying customers, Thomasson said.

Insurance-market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions. "Again more paying customers," she said.