Jonathan Cohn takes you behind the scenes of negotiations between physicians groups and congressional health care reform legislation writers. The basic debate: docs -- at least the organized AMA docs -- fear that a Medicare-like "public plan" would mean, in the long run, significantly less money unless Congress artificially adjusts reimbursement rates. 


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.)

The AMA, according to the same sources, was part of these discussions. The fact that it has come out against the public option suggests, obviously, the talks aren't going that well. Still, a senior Democratic House aide points out the AMA's specific choice of language: A public option would not be "the best" way to deliver coverage. That's not quite the slamming the door, this aide says: "I see flexibility there."


So who speaks for docs these days? The AMA, weakened and defined as a conservative voice, is still the de jure voice, which explains President Obama's choice of venue. But plenty of other doctor's groups have reason to support public plans, particularly non-specialists and many specialist-generalists (i.e., oncologists who treat a range of cancer). Even if Congress can pass reform without the docs, they know they need to try to get the establishment to quiet down. Nothing was as damaging to health care reform efforts in the 90s as the organized effort by doctors to convince their patients that the government was about to ration care or force them to see another doctor.

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