Nurse practitioners, who have additional training in various specialties, as well as years of education and experience in medicine, are qualified to diagnose illness and prescribe treatment and drugs by almost any measure.

But when Rose Okoro, a nurse practitioner in Texas, opened a clinic near Houston seven months ago she had only enough patients to keep the clinic open part-time. This is not for lack of demand but because state law declares that she must be supervised by a physician or insurance will not reimburse her.

In a protest against a similar law in Pennsylvania, nurse practitioners argue they are qualified to do most things done by family doctors, understand their limitations and should be allowed to work independently.

You don’t have to look hard to find out why nurse practitioners are having trouble getting traction: The American Medical Association is one of the most powerful lobbies in the country, and has been since 1910 when they released the Flexner Report on medical schools. In response, Congress put the AMA in charge of setting standards for what must be taught to doctors. Over 30% of medical schools were closed over the next few decades. No new schools have opened since the 1980s.

Even before that the AMA was weeding out ‘lodge practice,’ wherein a doctor contracted with a mutual aid organization to supply his services to a group of people for one year, with all of them sharing the costs.

The AMA also forbids doctors from advertising their prices and from bargaining to lower their prices. By some estimates, artificially inflated physicians’ pay contributes more than three times as much as the uninsured do to wasteful healthcare spending.

All of this is classic cartel behavior. Milton Friedman’s 1962 book Capitalism and Freedom called the AMA “the strongest trade union in the country.” Yet, little to nothing has been done to break the power of the AMA. In fact, the Affordable Care Act has done much to expand their power, with little outrage from the public.

It’s strange that the AMA, despite general knowledge about its practices, remains essentially untouched by these revelations. For contrast, consider “Big Pharma,” which makes an excellent bogeyman: we are constantly presented with the narrative of faceless operatives far way who are conspiring to poison people for a profit.

But doctors are neither Big Business nor Big Government. The AMA does not easily fit into a left-wing or right-wing narrative. Perhaps this is the secret to why their less tasteful tactics slide under the radar. Dramatic stories require good and evil, but as caretakers, doctors are difficult to to paint as ‘evil.’

This is a concrete example of the true costs of the culture wars: While we distract ourselves with name-calling and flashy confrontations, real problems go unacknowledged and unfixed.