Frame Game

Look for the Union Doctor

Last week, when the Department of Justice filed an antitrust suit against the merger of two HMO giants, the American Medical Association applauded the suit and took credit for urging the government to file it. Insurers were “intent on capturing the medical marketplace,” seeking “too much power to dictate the health care options offered patients,” said AMA Chairman Randolph Smoak.

Two days later, the AMA voted to set up a doctors’ union and to lobby Congress for an antitrust exemption allowing all physicians to bargain collectively. Cynics suggested that doctors were abandoning the Hippocratic oath for hypocritical politics. To deflect this criticism, the AMA associated itself with favorable images of organized labor while dissociating itself from unfavorable ones.

1. We’re on your side. Chip Kahn, president of the Health Insurance Association of America (HIAA), which lobbies for HMOs, accused doctors of seeking bargaining power to raise their incomes “at the expense of American consumers and taxpayers.” To thwart this charge, the AMA portrayed HMOs as the true enemy of consumers, implying that doctors were taking on the HMOs in defense of consumers. AMA President Nancy Dickey said doctors would “battle insurance companies and managed care plans that put healthy profits ahead of healthy patients.” “Patient care is not at the top of health plans’ list of priorities,” Smoak asserted. “Our objective here is to give America’s physicians the leverage they now lack to guarantee that patient care is not compromised or neglected for the sake of profits.”

2. We’re the little guy. HIAA officials depicted doctors as a cartel, accusing them of pursuing “collusion” and “price fixing.” At a House hearing last week, Justice Department and Federal Trade Commission officials argued that exempting doctors from antitrust laws would stifle “competition,” limit “consumer choice,” raise costs, and reduce “quality.” The AMA ducked this critique by casting itself not as a business group but as an underdog alliance of working folks. Doctors are waging a “David versus Goliath” battle against the “abusive and unfair practices of insurance company giants” in a valiant effort “to level the playing field between patients and insurers,” said Smoak. HMOs treat doctors like “ditch diggers churning through patients,” added Dickey.

3. We’re not greedy. Unions have a reputation for shutting down important services and ignoring public inconvenience for the sake of greed. The AMA wants to avoid this reputation. “I don’t really believe [the AMA’s unionization] is being done for patients,” one academic health care analyst told the New York Times. “This is happening because doctors’ incomes, doctors’ sense of autonomy, are getting killed.”

To sidestep this complaint, AMA officials promised never to strike (though Dickey conceded doctors might resist bad employers by “being a little slow in completing some of the paperwork” required by HMOs) and avoided the word “union,” instead calling their proposed alliance “an affiliated labor organization.” The AMA’s disclaimers underscored the liabilities of the “union” label. “This will not be a traditional labor union. Your doctors will not strike or endanger patient care,” Smoak assured the public.

The basic political equation in medicine is that patients expect better care than they’re willing to pay for. When they’re deprived of options and benefits that exceed what they’ve paid for, or when they’re obliged to pay premiums sufficient to cover the options and benefits they expect, they figure some special interest is ripping them off. The AMA’s goal this week was to increase its bargaining power without appearing to be that special interest.

And what is the media’s verdict? Unionization shows “how aggrieved many doctors feel,” says the Washington Post. It changes the image of physicians who have “sometimes arrogantly presented themselves as part of an elite profession as opposed to members of a workers’ group,” says the New York Times, and it “may turn out to be a strong force against health plans that unfairly use their market power to limit quality of care.” Whether the doctors’ latest prescription will cure their ills remains to be seen. But they look great.