Amy Goldstein had a nice piece in last Friday's Washington Post exploring the AMA's fence-straddling on the health reform issue. Now, before I go any further, it's important to acknowledge that the AMA doesn't speak for all--or even most--physicians. There can be little doubt, however, that the AMA speaks more loudly than any other physician group, because it is well-organized, well-financed, and well-known. Why should we care if the nation's leading physician lobby is wavering on health reform? Because to date they have been largely uninvolved in the debate. If they suddenly enter the fray with gusto, they stand to greatly influence the final outcome of reform.
As has become abundantly clear by this point, health care reform has really been framed as health insurance reform, and the natural "enemy" of that effort has been health insurers--with America's Health Insurance Plans serving as the most visible target. No doubt, that approach was decided upon for largely political reasons. Specifically, the public tends to hold physicians in high regard, while insurers are more often the object of scorn. Thus, it takes much less effort to convince people that insurance companies need to be made more accountable than it does to convince people that their doctors need to make less money (or some such thing).
Now, I happen to think that health reform--done right--will require two distinct phases. The first is the creation of a revised payment structure and the second is the reformation of the provider-delivery system. I firmly believe that when the political calculations were being made, it became clear that a one-and-done effort at addressing both the payer and provider components of health care wouldn't be politically feasible. Why? Because the payer and provider groups would unite in their opposition, and history teaches us that such powerful entrenched interests are nigh impossible to overcome. Instead, I believe, the decision was made to employ a divide-and-conquer strategy. That means aiming for one target first, before following up with the second act. Of course, if you were paying attention earlier in this post, it should come as no surprise that insurers were first up on the chopping block.
But the AMA is made up of some pretty smart folks. I think they understand that they are sitting in the on-deck circle; that their livelihood will be coming under fire next. If, that is, part one of reform is successful. As the political strategy becomes more apparent, it seems increasingly likely that the docs are going to become more vocal in the debate. They sat on the sidelines for a while, content to let insurers catch the brunt of the reforms. Now, they may be rethinking that strategy, and planning to come to bat for the insurance companies, if only to save their own skin. Of course, the flip-side of their decision is that, if they oppose reform and it passes anyway, they will have spent whatever political capital they were amassing by sitting this one out so far. Consequently, Congress might bring the hammer down even harder during act two. Whatever the AMA decides to do, you can be certain that the decision wasn't made lightly.