AMA Opposing Public Option
I’ve been touting the inclusion of a robust public health insurance option as the best tool in our quiver for improving the efficiency of our health care system—slowing the growth in costs without reducing growth in quality. Needless to say, the inclusion of such a plan in a health care exchange would be bad for the private insurance industry, so they oppose it. Fortunately, the public hates the private insurance industry, so it’s easy to attack insurer attacks on the public plan. Unfortunately for public plan advocates like me the American Medical Association also opposes a public plan.
On the merits, this shouldn’t tell you very much. The AMA represents the interests of medical doctors and, of course, medical doctors don’t really have a big interest in making health care more efficient. After all, what looks like inefficiency to health care wonks looks like “income” to doctors. Defense contractors don’t like procurement reform, and when school systems try to reform their labor practices to better reward quality teaching, teacher’s unions tend to oppose it. Such is life. Incumbent stakeholders don’t like change, but when you have an inefficient system—like health care in the United States—it’s often very helpful to push change that incumbent stakeholders don’t like.
For example, including a public plan that reimburses doctors at rates based on the Medicare schedule could save a lot of money. And as Igor Volsky emphasizes “if Congress requires all providers who accept Medicare to also accept patients with the new public option” you could probably coerce a large proportion of doctors into accepting these rates. But the upshot here is less money for doctors. Which doctors don’t want. And unfortunately for the country, unlike insurance companies doctors aren’t unpopular, so if I run around saying “Jay Rockefeller has a great idea and only doctors hate it” people are going to give me funny looks rather than cheer.
45 Responses to “AMA Opposing Public Option”
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June 11th, 2009 at 9:24 am
My doctor friends (in their 30s) all say that the AMA is now perceived by younger doctors as a conservative wing of the profession — precisely the types who are most likely to want to preserve the status quo. The AMA, in other words, should not be taken as representative of “doctors,” but of older, establishment doctors. Thus, reform activists have a chance of hiving off younger or less hide-bound doctors.
June 11th, 2009 at 9:24 am
The AMA represents medicine like the Chamber of Commerce represents commerce, i.e. not at all. They’re lobbying groups for doctors and for big business, misleadingly titled because it’s easier to win if you cheat. There’s no reason for anyone else in the debate to honor the AMA’s false claim that it represents medical rather than physician interests.
June 11th, 2009 at 9:24 am
Let’s not forget that the AMA vociferously opposed Medicare in the 1960s, in part because they were afraid it would lead to national health care. I’d like to see an ad with Betty White or some other famous old lady saying, “If we’d listened to the AMA 40 years ago, we wouldn’t have our Medicare coverage today. They were wrong then, and they’re still wrong today.”
June 11th, 2009 at 9:32 am
Fuck the AMA, for the reasons mentioned upthread. (See also: the APA, erstwhile torture-apologists.)
And a plan that stuffing selected doctors’ mouths with gold — especially younger ones who are prepared to take on primary care or lower-margin specialisations — will be enough to create the right dynamic for reform.
June 11th, 2009 at 9:35 am
Well, that’s that. Failed presidency.
June 11th, 2009 at 9:35 am
As others are noting, while a public plan may create some losers among medical professionals, it will also create some winners. So I would strongly counsel against treating them as a block of losers–that is exactly what the losers want people to believe.
June 11th, 2009 at 9:36 am
All this will do is further the exodus of doctors from the AMA. They’re way out of touch if the doctors I know are at all representative.
June 11th, 2009 at 9:39 am
This year in polling 59% of doctors supported a goverment run universal medical insurance system. Only 15% of practicing doctors are members of the AMA.
June 11th, 2009 at 9:44 am
The AMA is definitely the conservative wing of physicians in the US, representing primarily the interests of wealthy specialists. However, unlike the fiasco in the 60s, this time they support a huge percentage of the reform agenda.
I’m generally opposed to the AMA, but I really can’t blame them on this point. Medicare and Medicaid (the latter particularly) have lower reimbursement rates and are known to be spotty (it can take forever to get paid and sometimes you don’t get paid at all). A lot of physicians lose money on Medicaid and basically take the patients as a form of charity. Now we’re looking at a situation in which 50% of patients could be on a plan which, depending on the details, could work a lot like that. Before you attack doctors, would you honestly agree to a 20% cut in your pay? Most of America certainly wouldn’t – they oppose new taxes to pay for health care. The AMA certainly aren’t angels in the reform effort, but they’re certainly not demons.
Furthermore, the AMA has been willing to support innovations like changing reimbursement structure to minimize overuse (for ex., the medical home) and prioritizing primary. This also results in a pay cut for physicians in the end. This leads me to believe that, in addition to pay cuts, is the (probably irrational) fear of a government takeover of the health care sector. Physicians value their autonomy even more than their wallets, and they just hate being told what to do by bureaucrats, whether they be from the government or the insurance industry. So if you were a physician who believed the government is inherently more bureaucratic than industry and more prone to slowly expanding its influence, wouldn’t you be opposed to the public option as well?
I know we had this debate a few days ago, but the public option is just far more hassle than its worth. Allowing MEDPac to institute new methods of payment, changing the employer health care benefit to pay for reform, improving health care IT, eliminating Medicare advantage, regulating the insurance market through the use of exchanges and benchmark plans that force them to compete on price, and prioritizing comparative effectiveness research could all result in very real quality improvements and cost savings.
June 11th, 2009 at 9:52 am
Before you attack doctors, would you honestly agree to a 20% cut in your pay?
If I was getting paid the amount that a very rich doctor was getting paid? Well, it would mean the children would enter fewer dressage competitions with their horses, and that would clearly be unacceptable.
This leads me to believe that, in addition to pay cuts, is the (probably irrational) fear of a government takeover of the health care sector.
Ah, “government takeover”, the Frank Luntz scare-phrase. Let’s see how many doctors are prepared to take a nice hefty salary or get paid on a per-capita basis, shall we? Is that too much of a “hassle”?
June 11th, 2009 at 9:58 am
[...] I said below I like what Jay Rockefeller is proposing in terms of a robust public plan with reimbursement rates [...]
June 11th, 2009 at 10:07 am
And so, queue up the next phase in the drama: Obama will make a speech directly to the AMA.
Hopefully it will debunk their stated reasons for opposing a public choice. Can’t wait…
June 11th, 2009 at 10:08 am
AMA has fought almost every major effort at health care reform of the past 70 years. The group’s reputation on this matter is so notorious that historians pinpoint it with creating the ominous sounding phrase “socialized medicine” in the early decades of the 1900s. “The AMA used it to mean any kind of proposal that involved an increased role for the government in the health care system,” Jonathan Oberlander, a professor of health policy at the University of North Carolina, told NPR in a 2007 interview. “They also used it to mean things in the private system that they didn’t like. So, at one point, HMOs were a form of socialized medicine.” Indeed, the role played by AMA throughout health care reform battles past has often been primarily as the defender of the status quo. In 1935, fears of an AMA backlash helped persuade Franklin Roosevelt’s advisers to drop a health care article from the Social Security package — fearful that the opposition would sink the legislation altogether. Concerned about government restriction on and oversight over surgical activities — not to mention the loss of physician income — the group deployed the “socialized medicine” argument to undermine Harry Truman’s effort at a national health care system years later. In 1961, AMA organized a campaign to block Medicare. Titled “Operation Coffeecup,” the effort insisted that the government-sponsored system would lead to a varying form of totalitarianism. For a spokesman, the group turned to Ronald Reagan, who lent his famous actor’s voice to a 10-minute plus recording.
June 11th, 2009 at 10:09 am
So if you were a physician who believed the government is inherently more bureaucratic than industry and more prone to slowly expanding its influence, wouldn’t you be opposed to the public option as well?
Maybe, but you’d also be an idiot.
June 11th, 2009 at 10:11 am
The AMA, contrary to what the mainstream media says, does not represent most doctors.
June 11th, 2009 at 10:35 am
Gay 73,
Says who?
June 11th, 2009 at 10:38 am
See, the Bush years have been terrible to liberals. Everything was so easy. He was so ridiculously wrong on everything that all we had to do was completely disagree with him, and we were probably right.
As a result, we’ve lost all ability to see any other point of view. I agree that bipartisanship is a bullsh*** phrase Republicans use to get what they want when they’re in the minority, but compromise is a very real thing. We can have a good healthcare system without a public option! And yet, the last 8 years have made some people so reflexively hostile that you get things like this:
“Maybe, but you’d also be an idiot.” “Well, it would mean the children would enter fewer dressage competitions with their horses, and that would clearly be unacceptable.”
The AMA agrees with 90-frickin-percent of the reform agenda. We have almost everything we want, except the public option. Therefore, the AMA must be idiots, doctors are rich spoiled brats, etc. Even the AMA, the most conservative wing of doctors, is agreeing to take a pay cut. Hell, they’re calling for it as part of their platform. It’s just not the particular pay cut you’ve fixated on.
June 11th, 2009 at 10:50 am
We can have a good healthcare system without a public option!
Let’s unpack that ‘can’, shall we? It is certainly possible to imagine a decent healthcare system without a public option; is it possible to get a decent healthcare system in the US without having a public option? Given the people who are sweating blood to prevent it, I highly doubt it.
(And my reference to the dressage circuit is not plucked from the air, Carlos.)
June 11th, 2009 at 10:56 am
False equivalency, maybe?
Teachers make salaries on par with doctors and defense contractors? Who knew?
June 11th, 2009 at 11:09 am
The reason that 59% of doctors support a government program of universal coverage is because they have seen that one bureaucratic payer is better than trying to figure out hundreds of them. I am the office manager in a doctors office. We have four full time employees working to file insurance for two providers.
Medicare Advantage plans are the best advertisement for a single payer system yet. Doctors are being convinced by the evidence that cannot be ignored that the single payer for medicare was better than the fragmented system of partial privatization that is the Advantage plans. If we had a single payer with a single set of rules governeing payment most doctors would likely see a pay raise as compared to the system we have now where there are literal hundereds of insurer rulesets making it near to imposible to collect all that one is owed.
Which system is better the one where you collect all of a payment schedule that is reduced by 75% or one where you colect 75% of your claims are rejected by the insurance companies’ multiple bureaucracies?
June 11th, 2009 at 11:13 am
I just love your gay joke! But, why not read the thread before commenting? Check out #8, oaf.
To Carlos – without the public option, these reforms are useless, like a US Constitution without legislators willing to enforce it. Knowutimean?
June 11th, 2009 at 11:26 am
Just curious… why hasn’t anyone in the Obama administration come up with the idea of bundling health insurance reform with malpractice insurance reform? It seems like a natural way to get the doctors on board.
June 11th, 2009 at 11:37 am
Why would the other reforms be useless? The govt runs 45% of healthcare, why is 60 such a game changer? The arguments I’ve heard are unconvincing.
1) Economies of scale: Medicare is already huge. There’s a lot of European countries smaller than Medicare able to achieve cost control.
2) Competition: Obviously there are market based methods to encourage competition. The exchanges, benchmark plans, etc. These are real, effective reforms.
3) Administration: This one I agree with. We need to find a way to reduce administrative overhead. But again, the govt runs 45% of health care already, the public plan won’t reduce admin significantly. Single payer would, but it’s not on the table. So we need to standardize billing and administration, but a public plan doesn’t address that.
June 11th, 2009 at 11:42 am
I should also mention that by far the biggest injustice in health insurance (besides people not being able to afford it) are the preexisting condition discrimation, whereby people are denied coverage or have it taken from them when they need it most. Eliminating this, which everyone is on board with, results in a much better insurance industry, public competition or not.
June 11th, 2009 at 11:43 am
Doctors are forced to pass on their costs to deliver medicine to the patients with private insurance. This is because Medicare doesn’t pay the “usual, customary and reasonable” expenses for the health care benefits the politicians guarantee people on Medicare.
What do you think will happen once doctors can’t do this because there isn’t a private insurance market? Answer: cut quality of care and eventually ration care altogether. Ain’t that nice?
If you think health care is expensive now, wait until its free!
June 11th, 2009 at 11:49 am
if Congress requires all providers who accept Medicare to also accept patients with the new public option”
Hey look, a gigantic public subsidy for the new public plan!
This is why the idea that the public plan will just provide “competition” is completely bogus. Where you have one plan with a gigantic public subsidy and another plan with no subsidy, there is no “competition”, there is only the government taking over the health sector.
June 11th, 2009 at 11:50 am
Really? Then the rates for doctors who don’t accept Medicare should be much, much lower than the rates for doctors who do. But they’re not. On the other hand, in countries where there is a public plan of some sort, health care efficiency is much higher, with comparable or higher standards of care. So, you’re just wrong.
June 11th, 2009 at 11:59 am
The Medicare reimbursements simply aren’t enough for primary care providers to make a living. Unless there’s reform in medical education costs (my wires student loans are $1000/month for 30 years) and in malpractice costs there will be an exodus of docs from primary care.
There’s a big difference between specialists and primary care docs in terms of pay. It’s wrong to think they are all rolling in dough.
June 11th, 2009 at 12:00 pm
This is because Medicare doesn’t pay the “usual, customary and reasonable” expenses for the health care benefits the politicians guarantee people on Medicare.
Nor do un-/under-insured people who incur large medical bills (often at the “artificially high base for the 80% insurance discount” rate) and end up bankrupt. Clearly, those writeoffs don’t count if you’ve decided that Medicare billing rates are the real problem.
June 11th, 2009 at 12:01 pm
@shygetz-those countries also subsidize medical education and control malpractice costs making it easier for doctors to make less money.
June 11th, 2009 at 1:24 pm
Ninety percent of the ideas is not 90% of the agenda. A public option is more than half of the reform agenda by itself. Opposing it is opposing reform, even if you agree with everything else.
June 11th, 2009 at 1:29 pm
The AMA tends to represent older, wealthier doctors. These doctors tend to have extensive investments in ancillary medical companies. Legislation that most doctors support could easily have a negative impact on the profits of companies that do testing, provide equipment etc., and therefore hit many doctors in the wallet indirectly.
June 11th, 2009 at 1:29 pm
“My doctor friends (in their 30s) all say that the AMA is now perceived by younger doctors as a conservative wing of the profession — precisely the types who are most likely to want to preserve the status quo.”
So, the AMA is the AIPAC of the medical profession?
*ducks*
June 11th, 2009 at 1:40 pm
“The Medicare reimbursements simply aren’t enough for primary care providers to make a living.”
That is only true in our current system where many do not have insurance and must be seen pro bono, and doctors fail to collect much that they are owed from insurance companies in many instances. If doctors knew that they would be able to collect at medicare rates for every patient they saw with no exceptions they would do fine.
June 11th, 2009 at 1:50 pm
[...] the interests of medical doctors and, of course, medical doctors don’t really have a big interest in making health care more efficient. After all, what looks like inefficiency to health care wonks looks like “income” to [...]
June 11th, 2009 at 2:45 pm
Medicare does suck for cognitive, non-procedural specialists. It also sucks for mental health. From my perspective, this is an argument for getting rid of Medicare’s lack of mental health parity. Reimbursement rates are low, and patients have to pay a 50% co-pay. It’s 20% for”medical” care.
June 11th, 2009 at 2:45 pm
Having healthy competition and a worthy profit motive are essential to the efficiency and quality of any system, including healthcare. A monopoly or almost monopoly of such a system creates enormous corruption, abuse, rationing, a drain on talent and innovation, an explosion of cost and a huge reduction in quality. This is not theoretical…one need only look at both the history of monopolies in this country and socialized medical systems abroad. A centralized authority dictating prices and procedures will invariably cause that system to fail albeit it may take a few generations. Every politican talking about socializing medicine has a vested interest in seeing it succeed; special interest groups will reward those politicians and the voting public will see it as “free” healthcare although there is nothing free about it.
June 11th, 2009 at 3:13 pm
A monopoly or almost monopoly of such a system creates enormous corruption, abuse, rationing, a drain on talent and innovation
I really don’t think the problem with the health insurance system is that we don’t have enough “innovation” and “talent.” In fact, I’d venture to argue that the insurance companies are engaging on “innovation” that helps them and relying on “talent” that could be better used elsewhere.
You keep confusing the health insurance industry with the health care industry.
A centralized authority dictating prices and procedures will invariably cause that system to fail albeit it may take a few generations.
Convenient! “This program will fail! Even though it will look like it is working until long after we’re all dead!”
June 11th, 2009 at 3:40 pm
It’s obvious that you haven’t actually looked at medical systems abroad. Yglesias himself posted a study recently which showed that on most metrics, the Canadian and US systems were roughly equivalent – even though Canada has universal health insurance and spends less than half of what the US does on health care per capita. Other systems abroad that spend more (but not as much as the US), like the French and German systems, are significantly better than the US system, even in terms of things like waiting for treatment.
Not really – Britain has had the NHS since shortly after World War 2, and it is doing fine (not as good as the US, but pretty good). Canada has had its system for nearly forty years now, and it’s by and large doing fine.
Besides, in the latter’s case, all the government is doing is acting as the sole payer on the “demand” side, by negotiating a series of rate schedules for treatments with doctors’ associations. Almost all of the care provided is by private, for-profit doctors and clinics that arise due to market opportunities profitable at the rates set.
It’s “free” in the sense that, aside from taxation, you don’t find yourself personally liable for every medical expense. Even in the case of people with insurance, most people are on the hook for costs due to things like deductibles and so forth.
Maybe, but if you look at the Canadian example, it might actually be the opposite effect – Canadian doctors at all levels make less money than in the US, but there is a higher ratio of primary physicians to the population in Canada than in the US.
June 11th, 2009 at 3:56 pm
as a doctor, I can sate with certainty the following. Most healthcare insurers pay only incrementally more than medicare for most billing codes. And the cost of that slight increase is beuracracy that encourtages routine denials and delays of payment. most physicians would be better off with a public plan that paid out medicare fees in a timely and simple fashion.
Having said that, the truth is that healthcare reform will not occur without physician reimbursements changing dramatically. Primary care physician must be incentivized to provide more preventitive healthcare, and reimbursements for referrals and procedures must decrease significantly. (the excess expense in healthcare is in the procedures, referrals, testing, etc… you save money by keeping patients healthier and avoiding them.) Many doctors will not like this. After all, once you make $500k/year, it is awfully hard to pay your mortgage on $175k/year. That is where the fight will come from (and those are the people that the AMA represents, not the family doc or local pediatrician).
One method to facilitate the change is to offer scholarships to medical school students contingent on accepting any public plans offerred. Soon, all new doctors (who are the doctors that older docs MUST use to make money off of, by paying them a fraction of what they bill, because older docs have reputations to gain patients but only so many hours in a week to see them) will have to accept a public plan, and the conversion will be inevitable.
June 11th, 2009 at 6:38 pm
Re: What do you think will happen once doctors can’t do this because there isn’t a private insurance market?
Um, cut their expenses? Like the rest of us do when our income takes a nosedive. Sorry, but I fail to se why doctors should be some protected class whose income must be guaranteed.
June 11th, 2009 at 7:04 pm
[...] Matthew Yglesias: On the merits, this shouldn’t tell you very much. The AMA represents the interests of medical doctors and, of course, medical doctors don’t really have a big interest in making health care more efficient. After all, what looks like inefficiency to health care wonks looks like “income” to doctors. Defense contractors don’t like procurement reform, and when school systems try to reform their labor practices to better reward quality teaching, teacher’s unions tend to oppose it. Such is life. Incumbent stakeholders don’t like change, but when you have an inefficient system—like health care in the United States—it’s often very helpful to push change that incumbent stakeholders don’t like. [...]
June 12th, 2009 at 11:03 am
You keep confusing the health insurance industry with the health care industry.
A centralized authority dictating prices and procedures will invariably cause that system to fail albeit it may take a few generations.
Convenient! “This program will fail! Even though it will look like it is working until long after we’re all dead!”
Semantics…I am not arguing the existing system is the best system. You cannot distinguish the healthcare industry from the health insurance industry because healthcare is a cost and the insurance industry is an important component of the cost.
As I have said, the history of government managed programs of this country and others shows that it is unsustainable. Continuity of success for our children and grandchildren should be an important component of this discussion. It is nothing more than self-interested narcissim to want something that future generations will pay the price for, as we see with the entitlement programs already.
June 12th, 2009 at 11:38 am
It’s obvious that you haven’t actually looked at medical systems abroad. Yglesias himself posted a study recently which showed that on most metrics, the Canadian and US systems were roughly equivalent – even though Canada has universal health insurance and spends less than half of what the US does on health care per capita. Other systems abroad that spend more (but not as much as the US), like the French and German systems, are significantly better than the US system, even in terms of things like waiting for treatment.
You are incorrect. I am in the healthcare field and have looked extensively at both single payer systems and free market systems and mixtures in between. I have read information from souces as varied as Matt’s and Brookings to CATO and AEI…the data is certainly, er, evaluated, shall we say, based on the side one falls on this issue. With the limited amount of major insurance companies competing today and the size of government involvement, one could hardly say we have a free market system in healthcare in America today. Often in many studies certain metrics are omitted or there are distortions based upon the surveyor, sample size, sample duration, etc. My point is all these systems are collapsing on their own weight. The question is what to do about it.
Not really – Britain has had the NHS since shortly after World War 2, and it is doing fine (not as good as the US, but pretty good). Canada has had its system for nearly forty years now, and it’s by and large doing fine.
Besides, in the latter’s case, all the government is doing is acting as the sole payer on the “demand” side, by negotiating a series of rate schedules for treatments with doctors’ associations. Almost all of the care provided is by private, for-profit doctors and clinics that arise due to market opportunities profitable at the rates set.
“By and large doing fine” is, of course, in the eye of the beholder.There are always trade-offs with every system…in the case of both Canada and Britain, there are endemic flaws which the American people may grow to tolerate, but there is no comparison as to the damaging effects such entitlement systems have had on these economies since WWII. Perhaps it is the reason why these countries are desperately trying to scale back the inexorable growth and ultimate collapse of their systems. Too much money, too few births, too few workers paying into their systems…as I say, look down the road and see where it heads…
Also note….the Canadian government is doing much more than just “negotiating with doctors associations” when it comes to managing the costs of their health care system. As they say though, the grass is always greener….
June 12th, 2009 at 5:31 pm
[...] leverage to lower health care costs, Matt Yglesias argues that “medical doctors don’t really have a big interest in making health care more efficient“: After all, what looks like inefficiency to health care wonks looks like “income” to [...]