WP: Until there is actual legislative language, we will see the industry continue to be in favor of reform and portray themselves as coming to the table with solutions. They will try to persuade reporters that the industry has changed this time. They are saying the same things now that they said before. A lot of young reporters weren’t around then, and don’t know what they said in ’93-’94.

TL: What can we expect from insurers after the bill language appears?

WP: It’s what we won’t see—what goes on behind the scenes—that will be most important. The industry conducts what I call duplicitous PR campaigns—one of which I refer to as the charm offensive. They talk about how much they are committed to reform. But, behind the scenes, they are financing efforts to kill elements they are opposed to, or they kill reform entirely. They will work through what they refer to as “third-party advocates”—people and groups that are ideologically aligned with them—and use their PR firms and lobbyists to do that work. These surrogates will reach out to radio and TV talk show hosts and conservative editorial writers. Insurers will also activate their grassroots organizations—their employees, businesses, and political allies—and if their ability to make money in the Medicare program is threatened, they will reach out to senior citizens enrolled in their plans. Activities range from sending industry-written letters and e-mails to lawmakers and the media to flying people to Washington to lobby on their behalf. These are called fly-ins.

TL: Who are the industry’s grass tops, and how do they work?

WP: Grass tops are corporate executives and business leaders who develop relationships with elected officials. Insurance company executives routinely go to Washington to meet with members of the House and Senate. Companies’ lobbyists regularly meet with their staffs and bring plenty of “leave-behinds,” such as carefully crafted position papers and talking points.

TL: How much weight does that carry?

WP: Quite a bit. Even if an executive meets with a Democrat not perceived as an ally, just a meeting and an offer to be supportive is worthwhile. It improves or forms a relationship that might not otherwise take place. Executives want to be perceived as reasonable and cooperative—as people who have their constituents in mind. The executives don’t go to Congress to talk about medical loss ratios and profits.

TL: What else will we see?

WP: We will see front groups formed to attack any legislation or parts of legislation the industry doesn’t like. They’ve done this in past campaigns. They will use front groups to rip legislation to shreds. It’s inevitable that will happen again. It already is. You can be assured that the industry is behind the increasingly vocal opposition to the public plan that would compete with private insurers.

TL: Can you give an example?

WP: The Health Benefits Coalition was formed in the ’90s to fight anti-managed care legislation, including the patients’ bill of rights. It was funded primarily by big insurance companies, but it was portrayed as a broad-based business organization. The industry recruited the NFIB (National Federation of Independent Business) to be the primary spokesperson. Insurers and the NFIB have had a long history of being allies.

TL: Can you explain how the industry organized to fight Sicko a couple of years ago?

WP: Through one of its PR firms, it orchestrated a huge behind-the-scenes campaign that involved giving industry allies, including columnists and editorial page editors, very selective and often misleading information about the shortcomings of other countries’ health systems that were depicted as socialistic or government controlled. It created a front group to churn out press releases and statements criticizing the movie, and warning about long waits for care in Canada and the U.K. That’s what went on behind the scenes. What the PR firm advised insurance executives to say to the press was quite different. You might recall hearing executives and industry spokespeople dismissing Michael Moore as an “entertainer” and quickly adding that the movie served a useful role in focusing attention on the need for meaningful health care reform.

TL: What practices will the industry fight to the death to keep?

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.