BRICKMAN * ALLAN MACY BUTLER 359 remained emblematic of AMA inhibition of debate. Butler argued that the AMA consistently represented “majority opinion . . . [as] unanimous opinion,” ostensibly without violating democratic proce- dure (Butler 1944: 5-6). Medical journals conspired to present a united front, unwilling to air discord within the ranks. To make minority medical opinion known, Butler and other dissenters joined the Committee of Physicians for the Improvement of Medical Care, the Committee for the Nation’s Health, and the Physicians Forum. In Butler’s analysis, advances in medical science made medicine at once more effective and expensive. As more Americans worked for wages or salaries, they became increasingly unable to afford quality medical care. A gap between the actual and the possible sabotaged medicine’s effectiveness as it undermined its ethical commitment. Sta- tistics remained nagging reminders: among the industrial nations in the 1940s, the United States ranked eighth in infant mortality, twenty-third in maternal mortality, and sixth in tuberculosis. Unappeased by the AMA’s belated acceptance of voluntary health insurance, Butler collaborated with other medical reformers to pro- mote government sponsorship of health coverage. For Butler, volun- tary insurance perpetuated the most insidious feature—fee for ser- vice—of medical practice. He warned that by combining fee-for- service with third-party payments, voluntary health insurance invited extravagance, removing checks on patients’ malingering and physi- cians’ overtreatment (Butler 1969: 476; Butler 1944: 4). Only with doctors on salaries or contract would, in Butler’s view, a national health insurance program be equitable and cost efficient. (Later in his life, he criticized the Canadian health insurance system, which remained fee-for-service, in effect punishing doctors and hospitals for patients’ health and rewarding them for sickness.) Yet Butler maintained that health insurance alone could not com- pensate for a delivery system marked by fragmented and uncoordi- nated services. While medical knowledge had become too vast for physicians practicing alone, 80 percent of illness properly fell within the domain of the general practitioner. Butler envisioned a web of health services, with primary care at community health centers served by a host of health personnel, including doctors, nurses, midwives, social workers, and nurse practitioners. Specialists working in hospi- tals linked to neighborhood health centers would see patients on referral from primary care physicians. Toward the end of his life, But-