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 a good time to look at just what kind of seats special interest groups will have at Obama’s table, and what they’re doing to bring the public around to their ways of thinking. This is the fourth 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 last graph of a relatively recent New York Times story hinted at the politics of health reform. The story, a rather routine piece about a Congressional Budget Office report, described the potential savings from various cost containment nostrums. At the end of its story, the Times revealed what’s at stake. Medicare is scheduled to cut doctors’ fees by 21 percent in 2010 and by 5 percent in each of the next few years. If those cuts materialize, the government would save $318 billion over the next decade, far more than would be saved by other remedies.
In a presentation to Congress, acting CBO director Robert Sunshine amplified this point: “Significantly reducing the level of growth of health care spending would require substantial changes in the incentives faced by doctors and hospitals to control costs,” he said. Translation: to really reduce medical spending, doctors and hospitals might face cost controls that could lower their incomes. The American Medical Association successfully fought this possibility every time health reform rose on the national agenda, and it’s a good bet they will fight again, while angling for a prominent place at Obama’s table.
In the current round of reform mania, the media have hardly discussed the role of doctors and other health professionals. For starters, they have given gobs of money to Obama and to those legislators who will be gatekeepers for reform. According to Opensecrets.org, the Web site of the nonpartisan Center for Responsive Politics, health care professionals—including doctors with lucrative specialty practices as well as dentists and nurses—rank sixth out of eighty-some industries in campaign donations this year, spending nearly $87 million on various candidates, with more than $10 million going to Obama. Senate recipients include influential Republicans John Cornyn and Mitch McConnell, who got about half a million dollars each, and Senate Finance Chairman Max Baucus, who got almost $360,000. That’s not chump change.
In the House, key players Pete Stark, John Dingell, and Frank Pallone each received more than $250,000. Opensecrets.org shows that the doctors’ primary lobbying organization, the American Medical Association, has spent freely on lobbying as well as donations. Out of various powerful interest groups, the AMA ranks second over the last ten years in the amount it has spent to influence Congress. Its $195 million is a little less than half of what the top-ranked U.S. Chamber of Commerce spent on lobbying.
Money isn’t the only thing the press should examine. Like its insurance industry brethren, who have tried to make themselves look conciliatory and helpful this year by crafting their own health proposal, the AMA is also professing its concern for the uninsured, even calling itself the “Voice for the Uninsured.” “Being uninsured isn’t just a statistic or a problem—it’s a tragedy,” says the AMA Web site, going on to promote the AMA’s remedies, which the association calls “common-sense solutions designed to empower American families.” Its proposals, called the “three pillars of reform”:
Provide all Americans with the means to purchase health care coverage.
Give families choice in selecting appropriate coverage.
Promote market reforms that enable this new approach.
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Please understand that the AMA, physicians, nurses and the ANA are four distinct and often competitive, constituencies. Physicians continue to be very worried about perceived territory and practice control threats by nurses. Nurses only enjoy about a 10% rate of collective representation - and the only groups of nurses who are represented are those deemed as non-managerial. To confuse further, the nurse administrator group has organized under the American Organization of Nurse Executives as a subsidiary of the for-profit American Hospital Association, and these nurses exhibit corporate loyalty and fealty to employers much more than to nurses and patients. The American Nurses Association continues to lose nurse members and has been eviscerated in its feeble efforts at joining in healthcare reform. It only has produced a single, out of date white paper addressing just a few key parts of reform, while mostly focusing on tangential secondary issues.
However, reporters would do well to look for professional nursing failure or absence at the root of every clinical problem and preventable error which results in harm or death. It's the key piece of stories which to date have not been reported. But to gloss over the specific role of professional nursing in protecting patients' safety and assuring that their healthcare is coordinated and provided correctly in a timely manner and in the right setting is to miss the crux of the story.
Finally - hospitals account for only one setting and part of the healthcare infrastructure. The majority of healthcare services are delivered in ambulatory settings - offices, clinics, labs, etc. Another significant percentage of services is delivered in long term care settings: nursing homes, inpatient rehabilitation settings. It is not sufficient or accurate to portray hospitals as the sole care setting stakeholder. It is also incomplete reportage to list costs from care as solely arising from hospitals. The balance of services, spending, costs and patient outcomes should always include preventive/primary/public/ambulatory versus tertiary/high tech/high complexity/high cost/inpatient
#1 Posted by Annie, CJR on Wed 7 Jan 2009 at 03:13 PM
Annie's point is well taken, and I would add some more about physicians.
Surveys of physicians show the majority of us are ready for serious healthcare reform, including a sizeable number for a single-payer system. Aside from Physicians for a National Health Plan, most of us do not have a voice. AMA, by policy at present, opposes single payer for ideological reasons and PNHP, at this point advocates only single payer. That leaves many of us without a political voice, as most of our specialty societies do not weigh in on such matters. A few do, but most do not.
Those of us who favor a universal system such as those of Germany or Switzerland, but who may not be prepared to endorse single payer, are without a real voice. Some of us are trying to organize, and with some luck, we will be able to put together some leadership that will be allowed at the table to offer an approach that might reflect the majority of physicians and patients.
#2 Posted by cmhmd, CJR on Thu 8 Jan 2009 at 06:34 PM