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As any good politician would, President Obama is trying to persuade skeptics to support his proposals for health care reform. On Monday, he spoke to the annual meeting of the American Medical Association, which has already made clear its reluctance to endorse one of the most critical components of the president's plan -- government-sponsored health insurance.

Obama believes a public health insurance option is a necessary alternative to private health insurance, which, as a profit-driven mechanism, can be both costly to consumers and stingy in its coverage. The president says a public insurance option can be paid for with premiums (rather than tax dollars) while still offering consumers the coverage they need.

You'd think the AMA would be enthusiastic about a plan that would allow more people health care at a lower cost. Not so. Though its spokesmen have backpedaled from their initial response to a public plan -- which was something like "hell, no" -- the group is still testy over the idea of any major reform to the creaky and frustrating machinery we euphemistically call a health care "system."

There are many hardworking physicians who want nothing more than to provide the best care for their patients, with little concern for their own enrichment. But other doctors jealously guard their profits, resisting any efforts they think will affect their bottom line.

Fortunately, Obama refused to bend over backward for self-interested physicians. To restrained applause, he spoke up forcefully for the public health insurance option.

Obama knows an important truth about the AMA: It has fought health care reform since the 1930s. The group famously opposed the creation of Medicare, hiring a California actor named Ronald Reagan to record a speech denouncing it as a communist plot. In the 1990s, the AMA helped to kill President Clinton's reform initiative.

Let's face it: The battle over health care reform is all about the money. Health care is a $2.5 trillion industry in this country and accounts for about 20 percent of the U.S. economy.

But here's the funny thing: For all the money this country spends on health care, Americans are by no means the healthiest people on the planet. Average lifespans, as just one measure, are shorter in the U.S. than in several Asian and European countries.

A study by Dartmouth Medical School researchers has compared Medicare spending around the country and documented huge disparities that cannot be explained by differences in patients' underlying health. And the increased spending, the study found, doesn't make patients any healthier.

That research has been highlighted by Dr. Atul Gawande, a Harvard-affiliated surgeon, whose recent New Yorker article focused on a Texas border town, McAllen, where Medicare spending is about $15,000 per enrollee, twice the national average. Yet, McAllen's elderly have similar medical problems to those of Medicare patients in El Paso County, where Medicare spending averages about half as much. What made the difference In McAllen?

"The across-the-board overuse of medicine," Gawande concluded, including generous use of doctor-owned medical services, which helps McAllen physicians fatten their wallets.

If all Medicare services were in line with those in lower-cost areas, the nation might save as much as 30 percent a year on health care costs, according to Peter Orszag, Obama's budget director. Patients might also be healthier, since unnecesary, invasive procedures can kill.

This ought to be the easy part of the battle over health care reform, since it doesn't involve the difficult choices over, say, exorbitant spending for terminal patients. Putting a pricetag on the final months of life for a middle-aged cancer patient will involve agonizing ethical and emotional decisions.

Still, reining in spending by physicians like those in McAllen will be challenging -- very challenging. It involves money, after all. And battles over money have a way of bringing out the worst in humankind.

(Cynthia Tucker can be reached at [email protected])


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