The Health Reform Debate: Where Are the Doctors?

April 10, 2007


If substantial healthcare reform occurs at the national level, it will be the most significant overhaul of our medical/economic system since the creation of Medicare and Medicaid in 1965. The decades-long struggle for that legislation was marked by significant opposition from the American Medical Association and other doctor-based organizations. The pejorative expression “socialized medicine” was an AMA favorite in those years.

Back in 1961 the AMA funded a slick (if ultimately unsuccessful) anti-Medicare program whose highlight was an LP featuring the sonorous voice of Ronald Reagan, in his first foray into politics. (More on that here.) The AMA was also instrumental in blocking the Clinton Health Plan in the 1990’s. So far the it and other physician-centered groups have yet to adopt the same high-profile role they took in previous health policy debates.

As they used to say in old movies: “It’s quiet out there. Too quiet.” Are organized physician groups like the AMA about to turn up the heat on health reform? And if so, what will they say and how will it affect the debate? Policymakers and others with a vested interest in the topic should be aware of the changing role doctors may play in the ongoing national “conversation” over healthcare.

A number of societal factors have changed since the 1960’s, and even since the 1990’s. The medical profession is respected in most countries for its level of education and its historical dedication to the well-being of others. But postwar America held doctors in a form of reverence unknown elsewhere.

Doctors were not to be questioned or challenged. It was assumed that they were wiser than most others, and that they acted with only the interests of the patient at heart. Elderly Americans thought nothing of addressing a man (and it usually was a man) younger than their children as “Doctor” while he in return addressed them by first name.

Much has changed since then. Whatever negative feelings Americans may have about managed care, the process of finding health plan-approved doctors and seeking authorizations for treatment has made the public aware that there are wide divergences of opinion in the medical profession, and that doctors’ opinions are no more immune to criticism than other people’s.

Highly publicized medical malpractice cases have exposed the public to egregious medical errors, further puncturing the veil of infallibility that once encircled the medical profession.

As a result of these social changes, physician groups like the AMA can’t count on having the same impact on public opinion that they once had. The Norman Rockwell vision of the kindly physician bent over the ailing child has been replaced by a more complicated and sometimes bewildering array of images.

What’s more, there is much greater diversity of opinion among doctors about health reform these days. The AMA and like organizations found far greater resistance to its 90’s-era political efforts than it had in previous years, and the percentage of American doctors who were AMA members declined significantly.

The AMA takes a softer approach these days. Its website describes the organization as “committed to leading the response of America’s physicians to solve the health coverage crisis for all uninsured patients.” They say they are for “incremental measures” in the short term. For the longer term they support “a consumer-driven, market-based plan to expand coverage through tax credits and insurance market reforms.” This is similar to the Bush “reform” package – which is to say, it isn’t reform at all.

Another group of doctors is represented by Physicians for a National Health Plan. PNHP and its 14,000 members represent the other end of the spectrum, committed strongly to a national health plan and rejecting any public/private collaboration.

(I’ve had a lengthy and rewarding email exchange with PNHP policy analyst Nicholas Skala, who originally wrote me objecting to my criticisms of the “single payer or bust” position, and to my qualified support for the Edwards plan – a plan that includes a role for private insurers. Nick’s a very knowledgeable guy, and we’ve basically concluded we have differing tactics but the same goals. I hope to examine the issues raised by that discussion in print at some point.)

Doctors are far from a homogenous group these days, in any case. As with the rest of society, income disparities in the physician community are much greater now than they were in the 1960’s, and surged at the end of the 1990’s. Successful cardiac surgeons, for example, earn two or three times the amount that an internist or family practitioner may make.

That disparity between specialist incomes and those for primary care practitioners continues to grow, leading to a declining number of new physicians in primary care. That decline raises medical and policy concerns not unlike those of the 1980’s. In addition to having an impact on the policy debate, this gap in income likely to generate division within the physician community over the type and extent of reforms to be enacted.

The fact is that the interests of general practitioners and highly compensated specialists are different. The role of doctors in the reform debate will be shaped in part by these differences in motivation and interest.

Physicians remain the highest-paid professionals in the country(1), but the fact that physician income declined during the late 1990’s and early 00’s only adds to the potential for heated disagreement among physician groups.

In that sense, the current debate is not all that different from the debate about managed care that took place in the 1980’s. In those days I, a young consultant and data analyst, found myself welcome to speak to associations such as the American Academy of Family Physicians. My topics usually concerned managing the overall welfare of patients with data provided by the health payer (either the HMO, an insurance company, or a government agency).

These physicians hoped that managed care would increasingly use them as “gatekeepers” to other, more costly forms of medical service. Managed care specialists and health policy analysts hoped in turn that the “gatekeeper” model would increase the use of less costly (and more humane) “cognitive services” (i.e., talking to patients) instead of highly costly tests and surgeries that may not be medically necessary.

That was not to be, for reasons that are beyond the scope of this piece. The division between specialties is instructive, however, as we consider the role of doctors in a policy debate that’s just beginning.

Things will really begin to heat up when policy discussions move into more detailed examination of how to best manage the increasing costs of American healthcare. Doctors can stand together when it comes to attacking our system for its top-heavy administrative expenses. But when talk turns to the high rate of certain surgeries and other expensive procedures in this country – procedures that have not been shown to improve overall health – those old fracture lines will appear in the physician community once again.

To quote Bob Dylan: “Things should start to get interesting right about now.”

(1) Thompson, William; Joseph Hickey (2005). Society in Focus. Boston, MA.


4 Responses to “The Health Reform Debate: Where Are the Doctors?”

  1. Richard,
    fyi, associations representing 330,000 physicians have joined together to promote the “medical home” model of primary care. See
    This is a well reasoned initiative.

  2. WE all have to take better care of our selfs….this will reflect on us a little but on our kids it will have a deeper impact

  3. Nathan Says:

    Just a correction, doctors in the US have held a higher status in general even before WWII. Some of this is because on average the typical American physician has 4 years more training than their European counterparts, some because American physicians work much longer hours and pay much more for their education (and in turn have higher salaries).

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