Having considered four of the major corporate stakeholders in our medical industrial complex -- the insurance, drug, and hospital industries as well as business -- it is now time to turn our attention to organized medicine. Since physicians order almost all services that are provided within our health care system, they are obviously a key player and interest group in the debate over health care reform.
Organized medicine has a poor track record in terms of reform. Although a universal system of health insurance was considered favorably for a short time by a committee of the American Medical Association (AMA) during Teddy Roosevelt's abortive attempt to establish such a program during the 1912 to 1917 period, the AMA has played a consistently reactionary role against such reform since then.
During the 1930s the AMA was a much stronger political force than it is today, to the extent that FDR did not include national health insurance as part of his New Deal policies. Three decades later, the AMA fiercely opposed Medicare as socialized medicine and a government takeover. It jumped on the bandwagon only after the American Hospital Association and Blue Cross got together in its support. Its initial opposition, however, soon turned to making best use of the program. Physicians' fees jumped almost eight percent in the first year after the program was enacted, more than twice the rise in the consumer price index.
Since World War II, organized medicine was fragmented into many smaller specialty and sub-specialty groups. As specialization advanced in following years, the AMA lost much of its political influence. Its membership dropped by 20 percent between 1993 and 2004. Of the approximately 900,000 U. S. physicians today, the AMA's membership is less than one-quarter, and the "house of medicine" is split into some 180 specialty and sub-specialty organizations and societies.
In the late spring of 2009, President Obama was busy getting the major stakeholders aboard his train for health care reform. We have seen how the insurance, drug and hospital industries made specific pledges in an effort to help pay for reform. While organized medicine made no such specific pledge, it was offered a deal by the White House if it would give its general support to the reform effort.
Once again, it was all about money. Whereas physicians had been facing cutbacks each year in Medicare reimbursement, usually reversed by Congress, the Obama Administration offered $245 billion to physicians as the "doc fix". At first, the Administration did not want to count this amount as costs of reform, but the CBO soon scored it as the additional costs that they are, coming up with a $239 billion increase in the federal deficit over the next ten years.
So what are the attitudes among these many physician organizations toward the various reform proposals working their way through Congress? True to form, the AMA and most groups are supportive of anything that will increase their reimbursement while opposing much else in the proposals. Reassured that the "doc fix" would provide more generous Medicare reimbursement (about 20 percent higher than it would have been under the original formula), at least for a time, the AMA and American College of Surgeons (ACS) expressed their support for the center piece of the reform bills -- efforts to expand affordable health insurance through employer and individual mandates, subsidies for lower-income people to purchase insurance, and expansion of Medicaid. But for the AMA and most medical organizations, that is where their support melts away. Instead, they vigorously oppose these provisions:
• The public option. In a letter to the Senate Finance Committee, the AMA had this to say: "Creating a public health insurance option for non-disabled individuals under age 65 is not the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans."
• An empowered independent Medicare rate-setting commission. The AMA and ACS quickly expressed their opposition when White House budget director Peter Orzag proposed a new federal commission with the authority to set payment policy for physicians, hospitals, and other providers.
• Targeted Medicare reimbursement cuts. In July 2009, the Administration proposed a plan to cut Medicare payments to cardiologists and oncologists by more than 10 percent each while increasing reimbursement to family physicians by 8 percent and nurses by 7 percent. This prompted leaders of the American College of Cardiology to warn that "The cuts could have the unintended consequences of rationing care, especially in rural regions with a large number of Medicare patients. In other areas, specialists may decide to pull out of Medicare, or ask patients to make up the difference with higher out-of-pocket payments."
Organized medicine has become so fragmented that no one group speaks for the profession. In fact, some groups have endorsed major health care reform, even to the point of single-payer national health insurance (NHI). As the second largest medical organization in the country with some 125,000 members, the American College of Physicians (ACP) has endorsed single-payer as one of two major options to reform our system. The American Public Health Association (APHA) has come out in favor of NHI. And of course, Physicians for a National Health Program (PNHP), a growing organization with 16,000 members, has pushed strongly for NHI since it was established in 1989. Meanwhile, many physicians across most specialties have come to see NHI as the only way to provide universal access to affordable health care. A large national survey involving more than 2,200 U. S. physicians in 2008 found that 59 percent support government legislation to establish national health insurance.
In our next post, we will reassess how the "alliance" of these five major stakeholders stack up for or against reform proposals being fought over in Congress.
John Geyman, M.D. is the author of The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008. With permission of the publisher, Common Courage Press
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