AMA reporting needs a second opinion

Thursday's New York Times article about the American Medical Association's opposition to the inclusion of a strong public option in health care reform had several serious flaws. As a result, it greatly overstated the significance of the AMA's stance and left out key information that undermines the group's claims.

The most basic flaw in the Times article is that it never made clear who the AMA represents. The article's headline described the AMA as a "Doctors' group." The second paragraph said it "is America's largest physician organization," with "about 250,000 members." The eighth paragraph said the AMA "probably has more influence than any other group in the health care industry." And the 13th described the AMA as "an umbrella group for 180 medical societies" before finally acknowledging it "does not speak for all doctors."

In fact, the AMA speaks for less than one-third of doctors. There are somewhere in the neighborhood of 800,000 physicians practicing in America today, so the AMA's 250,000 members constitute only about 30 percent of all doctors.

Are the views of AMA members representative of the views of all physicians? The Times didn't even begin to address that question. The Atlantic's Marc Ambinder reported that "the AMA's members tend to be more skeptical" of comprehensive health care reform "than the average doc." Matthew Holt of the widely respected Health Care Blog said the AMA "in general over-represents specialists and those in small practices." The New Republic's Jonathan Cohn added that the medical community does not "speak with the same unified, conservative voice it once did. ... Primary care physicians in partiuclar [sic] -- organized through groups like American Academy of Family Phyisicians [sic] 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."

The Times' only indication that other doctors' groups might support a public option came in the 13th paragraph:

One group, Physicians for a National Health Program, supports a single-payer system of insurance, in which a single public agency would pay for health services, but most care would still be delivered by private doctors and hospitals. In recent years, some doctors have become so fed up with the administrative hassles of private insurance that they are looking for alternatives.

The Washington Post's Ezra Klein, however, noted that there are others:

Take the National Physicians Alliance. It's a newer, smaller, younger association of doctors. It sees the interests of doctors as inseparable from the interests of patients. It supports a public plan. Or check out Physicians for a National Health Care Plan, which see the interests of doctors as irreconcilable with the interests of insurers. It's for single-payer.

Indeed, National Physicians Alliance policy chair Chris McCoy blasted the AMA's opposition to a public plan and renounced his membership in the AMA. That suggests the AMA may not speak for its own members, much less all doctors.

McCoy's open letter to the AMA brings up another way the New York Times article failed to give readers the proper context. The article made no attempt to assess the incentives the AMA might have to oppose a public plan, or to explain where the interests of doctors might diverge from the interests of patients and of the uninsured (or, for that matter, where their interests might overlap.)

McCoy highlighted that aspect of the AMA's opposition:

In reading the response, I was frustrated and disheartened by the fact that you couldn't get through the second paragraph before bringing up the issue of physician reimbursement. This merely highlights how the AMA represents a physician-centered and self-interested perspective rather than honoring the altruistic nature of my profession. As a physician, I advocate first for what is best for my patients and believe that as a physician, as long as I continue to maintain the trust and integrity of the profession, I will earn the respect of my community. The appropriate financial compensation for my endeavors will follow in kind.

I encourage the AMA leadership to read Atul Gawande's recent article describing how physician culture drives up the cost of health care without benefiting patient outcomes. At the heart of this problem are physicians who have a vision of themselves as money-generating profit centers rather than professionals serving the public good. The AMA represents, and encourages, this mindset with its single-focus on physician reimbursement over all other health care reform issues.

The Washington Post's Klein added:

The AMA represents the interests -- which it tends to define as the profits -- of doctors. That gives it a slightly different perspective on the American health-care system. Judged as a health-care system, it's pretty bad, primarily because it's so expensive. But judged as a mechanism for funneling profits toward various actors in the medical industry, it's pretty good, primarily because it's so expensive. Things that would make it cheaper -- like a public plan -- will inevitably cut into the profits of doctors. And the AMA doesn't want that.

Again: The New York Times article didn't so much as hint at the possibility that the AMA's position might have anything to do with doctors' profits; didn't so much as hint at the possibility that the AMA's interests and the public's interest might diverge.

Nor did it give any indication that the AMA's stance might actually backfire on the doctors it represents, as McCoy argued:

The AMA seems to be fixated on the fact that Medicare and Medicaid payments are lower than other payers. Let's go back to the history again: because the AMA opposed the creation of Medicare, physicians were not represented at the table when the system was designed. As a great policy wonk once said, "If you're not at the table, you're on the menu." And thanks to the dismal leadership and short-sightedness of the AMA in the 1960s, physicians were not a full partner in the creation of Medicare. And we're still feeling the reprocussions [sic] of that today. And yet now in 2009, the AMA is going to repeat that mistake by opposing the public plan.

What else didn't the Times tell readers about the AMA? Though the paper emphasized the AMA's clout, noting that it "has historically had a strong lobbying operation" and has handed out nearly $10 million in campaign contributions to congressional candidates since 2000, the Times strangely didn't tell us what the group was trying to accomplish with all that lobbying and all those campaign contributions. In fact, the paper made no mention at all of the group's previous positions on health care reform.

Would you view the AMA's opposition to a public option differently if you knew the AMA opposed the creation of Medicare? Better get your news somewhere other than The New York Times -- like, for example, from The Huffington Post, where Sam Stein noted that the AMA "has fought almost every major effort at health care reform of the past 70 years" and that historians credit the group with "creating the ominous sounding phrase 'socialized medicine' in the early decades of the 1900s," which it used to describe anything -- including aspects of private health care systems -- that it disliked.

The AMA, according to Stein, helped persuade FDR to drop health care from Social Security. It helped defeat Harry Truman's attempts at a national health system. It fought against the creation of Medicare and Medicaid. And it poured millions of dollars into defeating Bill Clinton's efforts to provide universal health care.

But The New York Times didn't tell readers any of that. Instead, the paper said right up top that the AMA is "committed to the goal of affordable health insurance for all." You'd never guess the group has opposed every significant effort to actually provide affordable health insurance for all.

So the Times didn't tell readers much about who the AMA represents, what other doctors think, how the AMA's interests might diverge from those of patients and would-be patients, or how the AMA has approached health care policy in the past. The Times article ran nearly 1,000 words; surely it must have included detailed assessments of the AMA's claims, right?

Not exactly.

The Times quoted the AMA's case against a public plan:

The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is 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."

If private insurers are pushed out of the market, the group said, "the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers."

Is that true? Are there facts or credible assessments that contradict that conclusion? The Times didn't say.

The New Republic's Cohn doesn't think much of the AMA's claims:

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.)

Klein cited an estimate that a strong public plan would significantly lower the cost of health insurance:

[Post columnist David] Broder and the Post editorial board focus other portions of their arguments on the importance of cost controls, for instance. So it would be interesting to see them explain how many Republican votes you have to gain to justify losing a policy that would lower the costs of health insurance by nine percent a year, as the Lewin Group estimated a "level-playing field" public plan would do. And how many Republican votes are worth sacrificing a policy that would lower the cost of health insurance by between 20 percent and 30 percent a year, as the Commonwealth Fund estimated a "strong" public plan would do?

But The New York Times ignored the possibility that a public option would lower costs; no such viewpoint or fact was included in the article. The Times did, however, quote another industry group -- America's Health Insurance Plans, the insurance industry lobby -- agreeing with the AMA that a public plan could "significantly increase costs."

That, apparently, is The New York Times' idea of "balance" -- quoting doctors who oppose a public plan and insurers who oppose a public plan.

Jamison Foser is a Senior Fellow at Media Matters for America, a progressive media watchdog and research and information center based in Washington, D.C. Foser also contributes to County Fair, a media blog featuring links to progressive media criticism from around the Web as well as original commentary. You can follow him on Twitter and Facebook or sign up to receive his columns by email.