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What's Up, Docs?

The American Medical Association announced yesterday that it was coming out against a public insurance option. The official argument, as relayed in this story by Robert Pear of the New York Times, is that a public plan "threatens to restrict patient choice by driving out private insurers" and that "the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers."

The first argument, a common one, ignores the fact that a public plan would likely result in more choices--certainly, more meaningful choices--for most consumers. Harold Pollack has explained this before. The second argument is just non-sensical. Most studies suggest a public plan would cost less than private alternatives. (Remember, a new public plan wouldn't be free; people would have to pay premiums for it, the same way they do for private plans.) 

This isn't the end of the story, however, The AMA is not as powerful as it was in the mid 20th Century, when it was arguably the organization most responsible for blocking efforts at national health insurance. Nor does the medical community speak with the same unified, conservative voice it once did. Different types of physicians hold different views and speak through different organizations. Primary care physicians in partiuclar--organized through groups like American Academy of Family Phyisicians and the American Pediatrics Association--are generally more liberal and may well speak out in favor of the public plan, if they haven't already.

Meanwhile, public plan advocates in Congress aren't giving up. Over the past few weeks, according to sources, House committee staff have been involved in serious negotiations with representatives of various physician groups, attempting to win their overt support not just for reform but for a public plan option specifically. As an enticement, they've been promising to fix permanently the SGR problem--that is, the annually scheduled adjustment to the "sustainable growth rate" in Medicare, which threaten increasingly large cuts in physician payments before Congress inevitably postpones changes for a year. Reformers, including President Obama, have already talked about doing this; apparently, the offer the House Dems are making is to follow through on this and to make it a good, solid fix. (I say "apparently" because, while I've been told these discussions are taking place, I don't know the details.)

And then there's the other obvious way for winning over physicians: malpractice reform. There's been talk, here and there, of a change to malpractice that would offer physicians more protetction from frivolous lawsuits if they demonstrated compliance with certain quality and safety benchmarks--a potential win-win scenario, if properly structured, because it would ease physician anxiety while actually reducing the activities that lead to worse health outcomes. The AMA itself has raised this possibility, although it raises procedural questions for Congress: Can it be done without bringing judiciary committees into the mix?)

One thing is certain: The AMA's positioning makes for interesting atmospherics on Monday, when Obama addresses their national convention in Chicago.

Update: Well, look at that. The AMA says it's not necessarily opposed to a public plan after all. At least not right now. Whatever that means.

--Jonathan Cohn