PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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The characteristic American behavior called volunteerism got its start with Benjamin Franklin's Junto, and has been a source of comment by foreign visitors ever since. It's still a very active force.

The Association (5)

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American Medical Association

The American Medical Association has several hundred thousand physician members, all of whom consider themselves important members of their communities, hence important members of the AMA. "The Association" maintains a large, experienced, and frequently successful lobbying staff in Washington. It would be wildly impractical to permit every individual member of the Association to walk into the Washington office and give orders to the staff. Even when individual doctors have a very good idea, and the staff members thoroughly agree with it, it's never safe to assume the professional as a whole agrees. And in fact it is always possible to find some doctor who violently disagrees, no matter what the topic.

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House of Delegates

So, a couple centuries of experience led to a system of funneling physician opinion up the line to the House of Delegates, and passing it through that narrow neck of the funnel before it is released to the Washington office as "policy". Sure, a couple of knuckle-heads can sometimes block a good idea at the narrow neck of the funnel, just as an occasional Leonidas can save civilization at this Thermopylae, against a bad idea. Sometimes an idea slides all the way through on the first try, and sometimes it is necessary to build up a head of pressure behind it. The fundamental question before the House of Delegates is not entirely whether a proposition is a good idea or a bad one; an equally important question is whether it likely reflects the prevailing viewpoint of the profession.

My first salvo in the campaign to win AMA approval for Medical Savings Accounts was a letter to Jim Sammons, the Executive Vice President. He wrote back promptly that he had read the Medical Savings Account proposal three times, and still didn't understand it. Although my opinion of him was never quite the same, he did me the favor of demanding simplicity, to be more quotable. An IRA for Health. An IRA plus a catastrophic policy. What's good about that? Cheaper. What makes it cheaper? Compound interest. How does it help poor people? More people can afford to buy something that's cheaper. Sammons said, ok, I can live with that.

The letter to the EVP turned out to be a good idea because it established my claim to ownership. A few months later I arrived in Chicago with a crisp, brief zinger of an MSA proposal, only to find that somebody from Louisiana was attending the same meeting with an almost identical proposal, called CHIP. Mike Smith was president of the Louisiana Medical Society, and not only had the same idea, but personally had a lot of Louisiana oil money which he freely spent on professional packaging of his presentation. Mike and I suspiciously circled each other like two wildcats for a few hours, but we had so much in common that very shortly we were the best of friends, remaining so for years until his unfortunate death. He introduced me to his Southern friends, I introduced him to my Northern ones, and the idea itself picked up some allies on its own merits. It had a fairly easy time of it in the House of Delegates. However, it was referred to a committee for polishing and deeper consideration. Six months later it had disappointingly picked up quite a lot of unforeseen opposition, probably after the hospital and insurance executives heard about it. It took another six months to fight through a wall of specious argument, but endorsement of the Medical Savings Account did become policy of the AMA, and the eager Washington staff was thus free to run with it.

It has remained AMA policy ever since, and the main technical problem for its main sponsors became one of keeping the idea alive in a House of Delegates with constantly shifting turnover. The AMA is like the court system; it doesn't like to keep revisiting an issue that is settled policy. Too many other members have proposals requesting attention, so why should we go on reaffirming old matters? However, the proposal was stalled in Congress, and for momentum we needed to keep beating the drum with variations which somewhat stretched the patience of the more senior members of the House of Delegates. To them I apologize, with gratitude for their tolerance.

But what was the matter with Congress? What was the matter with the editorial page of the New York Times? I was always uneasy about protracted debate, because reducing the cost of medical care (from the patient's point of view) was apt to translate into reduced income for doctors. I was leading a profession of self-employed entrepreneurs into a proposal to cut their own income for the benefit of the public; how long could physician enthusiasm be maintained for that? I'm proud to say the answer is at least twenty-five years.

Even in retrospect, I am a little surprised that even such sophisticated students of medical economics could remain focused for so long. They might have come to regard the sponsors of MSA as being on an ego trip, or else nutty fanatics obsessed with a lost cause. Or they might have joined the young newcomers in fearing that such determined opposition at a national level might signify the opponents were somehow right to oppose it. The arguments advanced by the opponents really seemed to have very little merit, but perhaps in private it might be possible to sympathize with some embarrassing circumstances that explained the vigor of the resistance without crediting its excuses. Political debate after all, even in scientific organizations, quite characteristically wraps venal motives in a cloak of logic and altruism. I remained fearful for years that the House of Delegates would shrug its shoulders and let the opponents have their way. That they never, ever, did so was probably related to medical care being physician home turf; where you get used to hearing a lot of dumb arguments, but you don't have to credit them with any merit until merit is displayed. You can tell doctors a lot of fairy tales about architecture or investment banking perhaps, but if you talk medicine with them, you better have your facts.

Whenever my colleagues would privately draw me aside and ask why in the world a lot of people were so resistant to the MSA, I had to tell them I was not entirely certain. However, it was notable that three groups had important things to lose, and would probably fight to preserve them. The Medical Savings Account threatened the eighty-year-old pricing preferences between hospitals and insurance companies. Secondly it threatened the sixty-year-old preferential healthcare pricing for members of organized labor. And finally, the politicians who were so anguished about the uninsured population might possibly be more interested in preserving the grievance than achieving its solution.

I can never remember a private conversation of this sort that didn't satisfy the doctor who asked the question. And I also never met a representative of health insurance, hospital administration or organized labor who would admit any truth to it.

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