Who Will Be at the Table? Part XII

During the campaign, Barack Obama promised his cheering crowds that, when he rolled up his sleeves to work on health care, he would “have insurance company representatives and drug company representatives at the table. They just won’t be able to buy every chair.” Now is the time to look at just what kind of seats special interest groups are having at Obama’s table and what they’re doing to bring the public around to their ways of thinking. This is the twelvth of an occasional series of posts that will analyze their activities and how the media are covering them. The entire series is archived here.

The American Medical Association, aka the AMA, scored a big one with the startling announcement that it was “supporting”—that’s the AMA’s word, not mine—the House version of health reform legislation. In a letter to Ways and Means Committee chairman Charles Rangel, the AMA said the legislation included a broad range of provisions that “are key to effective, comprehensive health system reform”—and, it might have added, are also key to doctors’ happiness and financial well-being.

In particular, the AMA likes provisions that would: extend coverage to all Americans through health insurance market reforms (yes, that’s safer for doctors than national health insurance); provide consumers with a choice of plans (though the group was silent on a public plan); require individuals to have health insurance and offer premium assistance to those who can’t afford it (how can you go wrong helping the poor?); include prevention and wellness initiatives (we know how potent they are); provide additional funding for primary care without imposing offsetting payment reductions on specialty care (high-priced radiologists et al are home free); eliminate coverage denial for preexisting health conditions (additional insurance reimbursements will come their way); and repeal the hated sustainable growth rate formula that annually threatens to cut doctors’ fees (a good fix for docs, though not for controlling overall costs.)

The AMA’s internal and external PR folks must have been overjoyed by the media’s response. The AP issued a story saying that the AMA had “endorsed a liberal health overhaul bill that includes a public insurance option, a bold step for a traditionally conservative group with a checkered past on health reforms.” The AP called it the “strongest action yet” in signaling support for reform. Politico reported the group “strongly endorsed” the bill. The media’s general take: the mighty AMA, once the supreme obstructionist in the fight for national health insurance, had finally come around.

President Obama was joyous, too, saying “these doctors are joining the chorus of Americans who know that the time to reform what is broken about the health care system is now.” House Speaker Nancy Pelosi was so excited her office issued a “breaking news” e-mail about the announcement, and Rep. John Dingell, the bill’s chief sponsor, said the “AMA’s support should not be underestimated.” Liberal commentators were thrilled. Jonathan Cohn at The New Republic called it “an unqualified endorsement for the most liberal plan out there.” Dean Baker, co-director of the Center for Economic and Policy Research, said the endorsement was a “tremendous coup” that could encourage other groups to come on board.

However, a closer reading of the AMA’s statement was in order. First, the letter to Rangel did not mention the super controversial public plan patterned after Medicare, which the AMA dislikes because, as it said to the Senate Finance Committee, the plan “threatens to restrict patient choice by driving out private insurers….and likely lead to an explosion of costs that would need to be absorbed by taxpayers.” It said only that it likes consumer choice through a health insurance exchange. In recent weeks, the AMA has been fence straddling. At a meeting of delegates in June, the AMA resolved to “support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice, and universal access for patients.”

Second, the AMA letter says: “We urge members of the House, Education and Labor, Energy and Commerce, and Ways and Means Committees to favorably report H.R. 3200 for consideration by the full House.” That phrasing will allow doctors’ lobbyists to work behind the scenes to kill any provisions they don’t like, as they surely will. They are not saying they support enactment, and they don’t say what they will axe in the final deal.

Kudos to The Wall Street Journal for finding some clues to the AMA’s PR strategy; and those who think the AMA has caved should read its story. Reporter Janet Adamy interviewed CBO director Douglas Elmendorf about the agency’s scoring of the bill’s cost-cutting provisions. “This legislation says we’re going to raise doctors’ payments, and we score that with the cost it’s going to have,” Elmendorf told the paper. Then came this e-mail message to the Journal from Cecil Wilson, the AMA’s president elect:

Reforming the flawed Medicare physician-payment system is very important to the final health-reform package, as are covering the uninsured, medical liability reform and many other elements of the bill. AMA’s support for a final package will depend on all its components.

Translation: If doctor payments are cut to arrive at much needed savings, then the AMA may not support the bill.

Another clue comes from the Web site of the Center for Medicine in the Public Interest, which itself is involved in lobbying against a public plan. Is the AMA using its sister organizations, the state medical societies, to do the dirty work while putting on a smiley face for the rest of the world? Some state societies are grouping together to fight the public plan, and are “adamant” in their opposition to other bill provisions as well.

Dispatching doctors in the states to contact their legislators is powerful stuff. On its Web site, the Medical Association of Georgia urges members to contact their Congressional reps and says that a public plan “will ultimately lead to a government-run, single-payer health care system” and “a catalyst for the expansion of ‘clinical’ comparative effectiveness to ‘cost’ comparative effectiveness which will result in the rationing of care—driving a wedge between patients and physicians.” Kind of sounds like the old AMA, doesn’t it?

If you’re having trouble following all this, a quote from Niccolo Machiavelli might help: “For the great majority of mankind are satisfied with appearance as through they were realities, and are often more influenced by the things that seem than by those that are.” In this fight, nothing is at it seems.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.