The CMA has become part of the problem

By David J. Gibson, MD

The requisite for being a professional is holding the willingness to place calling above the self interest of the called.

The biggest issue facing California at present are not illegal immigrants getting drivers licenses. It is not balancing the budget or raising new taxes. It is not environmental issues such as off-shore drilling. It is not about identifying people by racial classification. All of these represent the content free issues that politicians use to divert attention from the real problem.

The real problem, every year California grows by about 500,000 people. Most are marginally literate. Most have few skills and virtually no capital. All need jobs to give them a foothold on becoming part of the mainstream. California needs to create, at a minimum, 250,000 new jobs each year just to maintain employment rate parity.

Unfortunately, California is hemorrhaging jobs at an unprecedented rate. This compounds the state’s structural unemployment rate problem. For the past decade, California’s unemployment rate has exceeded the national rate by 1 to 2 percentage points and that difference is growing.

To make matters worse, over the past decade state politics has turned shrill, static and shallow. It is increasingly dominated by wealthy special-interest groups like trial lawyers, consumer groups, corporations, unions and gambling tribes. The CMA is now recognized as a permanent player in the lobbying game here in Sacramento.

The CMA has become part of the problem.

In a speech not long ago Arnold Schwarzenegger proclaimed that "the people of this state do not trust their government. They feel it is corrupted by dirty money, closed doors and backroom dealings. They see the contributions (from special interests) go in, the favors go out, and the people are punished with wasteful spending and high taxes."

Governance here in California has descended into a collection of interest groups not bound together by any ideals. The recall succeeded because the voters rightfully concluded that the state’s government had become incompetent.

The CMA has allowed itself to become part of the problem here in Sacramento. It is expending its influence and resources in the preservation of authority through regulatory means. The CMA’s time is now spent protecting financial privilege rather than orienting itself toward the needs of the patient. To illustrate this point, two thirds of the CMA-sponsored bills before the legislature this year related to money (provider contracts, reimbursement rates, unfair payment patterns and scope of practice).

None of the resolutions from the reference committee on Science and Public Health (childhood obesity, physical education and nutritional standards in schools, incentives to promote health education for end-of-life care and elimination of racial and ethnic disparities in health care to name only a few) were designated as high priority by the CMA House of Delegates. All five of the approved resolutions by the House of Delegates were directly or indirectly related to the financial self-interest of CMA’s members.

The CMA represents a profession, not a special interest. Unfortunately, by engaging in the above activities, we have allowed ourselves to become yet another one of the 1,000 lobbyist that clutter the halls of the capitol and feed at the public trough.

By allowing this to happen, the CMA has alienated many of California’s most idealistic and talented physicians and has suffered a steady decline in membership as a result. An informed and engaged observer could argue that it is time to rethink and restructure the CMA to better serve its membership and the patients we serve.

Recommended structural changes in the CMA

The resurgence of representative democracy lies at the core for change both of state government and of the CMA. We need to fundamentally rethink the organization’s structure and how policy is made. The following represents a partial list of recommended changes that are intended to stimulate debate within the organization.

The CMA needs to unilaterally disarm

The problem - doctors are lousy lobbyists: Trying to preserve privilege by lobbying in the state legislature does not work for doctors or their patients. The CMA repeatedly becomes the stalking horse for more powerful interests that then turn upon the CMA in the next legislative session.

SB 2 (universal coverage) is a classic example. The CMA sponsored this legislation and became its chief spokesman fronting for a coalition consisting of the Democratic Party leadership, organized labor, plaintiff lawyers, consumer advocates, various other special interest groups, insurance companies and hospitals.

This bill, based upon estimates by both the California Chamber of Commerce and the Los Angeles Area Economic Development Corporation, mandates $5.7 billion in new spending by small business owners (some estimates run above $11 billion). Mercer Human Resource Consulting calls this measure "the straw that breaks the camel's back for small businesses here in California."

It's no secret that the AFL-CIO's John Sweeney made passage of this bill a very high priority. Unfortunately, the CMA alienated its traditional allies (the Republican leadership, the California Chamber of Commerce and the National Federation of Independent Business) by championing SB 2. It is interesting to note that of the 67 prominent citizens making up the Schwarzenegger transition committee, not one is a physician or a member of the CMA.

The ink is hardly dry on the Bill and our new found friends (the Democratic leadership and organized labor) have already stated that it will be necessary to enact stringent, across the board, cost controls next year. If this bill is signed, look for steeply discounted price ceilings for services based upon aggressively negotiated rates from the mammoth new state pool called for in this legislation. This pool will be "managed care on steroids."

Next year will likely be a replay of this year when the CMA was the clear loser in the workers' comp overhaul. Physicians' fees were cut and limited medical treatment for employees injured on the job was enacted. It should be noted that the trial lawyers and insurance companies, our new allies in SB 2, were unscathed.

In the end, California doctors found them selves isolated and fed to the sharks in the lobbying feeding frenzy surrounding changes made in workers' compensation. Inside bets have been placed that there is much more to come - soon.

The reform: the CMA should get out of the lobbying business. It is inordinately expensive, alienates most physicians, denigrates the stature of the profession in the public’s mind and does not work for anyone but the lobbyist and the politicians.

Terminating the CMA relationship with all lobbyists, public relation firms and influence peddling law firms is called for. Moving the CMA as far as possible from Sacramento, perhaps to San Diego, or better yet into a rural underserved community, would be advisable.

The CMA needs to rethink its structure and priorities

Representative democracies value government and organizations that are as close to the represented as possible. Many of the county medical societies in California are in disarray. They are barely functional and close to insolvent.

The majority of funding from the membership should be invested in building up the county structures across the state. Each should have a strong publication, similar to SSVMed that is edited and written by local physicians. These publications should explore the issues facing the community from multiple points of view and not only encourage but stimulate vigorous debate.

Disaffected physicians, who have dropped out or have never joined organized medicine, will be better able to re-engage through an organization that speaks to and addresses local concerns. Other than a small professional staff that supports the grass roots of the organization, the CMA should utilize no resources.

The CMA needs to rethink its leadership paradigm

I have the greatest respect for physicians who are willing to support organized medicine and volunteer their time in multiple committees, the House of Delegates, and invest their energies in the steep pyramid for leadership that makes getting into the NBA look reasonable.

I had breakfast in Chicago not long ago with a friend who was a former President of the AMA. I asked him if the time he had spent away from his family, friends and practice climbing the county, state and national leadership pyramid was worth the prize of leading the AMA. His answer, which surprised me, was no. The sacrifice exceeds the opportunity to effect change.

The problem with the current leadership paradigm - we are squandering our best talent. Physicians possessing the energy, intelligence and motivation to get into the public debate should be encouraged to run for local office, serve in the legislature and get elected to Congress. Physicians have traditionally shunned these venues with the vacuum being filled by lawyers, teachers, business men, nurses, etc.

The real action for public policy is not with in the CMA. It is in elected office. We need to encourage our best talent to move into that arena rather than training them to be ineffective, or worse, counterproductive lobbyist.

Understand that I am not advocating that these talented individuals enter the public arena with a "CMA agenda." We do not need another Christian coalition look alike. On the contrary, the more diversity of thought on display in the public debate, the better.

The CMA needs to recommit to the well-being of the patient

Organized medicine gains its stature when it serves the interests of the patient and not in protecting physicians’ self-interest. After all, the requisite for being a professional is holding the willingness to place calling above the self interest of the called.

We need to refocus our efforts on public health, education and research. Let the public forum determine how health care will be organized and paid for. Physicians interested in funding mechanisms need to engage in the public debate as individuals. It should be understood by all that they do not speak for the profession.

Resolutions from the Science and Public Health Issues Committee should, without exception, command the highest priority for support from the reformed CMA.


The above list of recommendations is not intended to be exhaustive. The recommendations are presented in the spirit of encouraging a creative debate where other, and no doubt better, ideas will come to the fore. It is time to stop and think creatively about the future. Organized medicine has much to contribute to the betterment of California in the future. We will not fulfill that mission if we continue down the road of liberal special interest pleading and privilege preservation in a dysfunctional government