(CHARLES REX ARBOGAST ~ Associated Press)
For all the president's popularity, the response he got Monday from doctors at an American Medical Association meeting was a sign his road is only going to get rockier as he tries to sell his plan to overhaul the nation's health-care system.
The boos erupted when Obama told the doctors in Chicago he wouldn't try to help them win their top legislative priority -- limits on jury damages in medical malpractice cases.
But what could they expect? If Obama announced support for malpractice limits, that would set trial lawyers and unions -- major supporters of Democratic candidates -- on the attack. Not to mention consumer groups.
Every other group in the health-care debate has a wish list and a top priority. Insurers don't want competition from the government. Employers don't want to be told they have to offer medical coverage to their workers. Hospitals want to stave off Medicare cuts. Drug companies want to charge what the market will bear.
Obama can't give all of them what they want. Instead, he's got to figure what's just enough to keep as many groups as possible on board -- without alienating others. It's a fine line for him -- and sometimes for them.
"It's a coalition issue," said Robert Blendon of the Harvard School of Public Health, an expert on public opinion and the politics of health care. "No major group is able by itself to sink health reform. But if numbers of them come together for different reasons, it could really hurt the direction the president wants to go in."
The doctors were only Obama's first house call. He'll be making his case to the other groups -- and to the nation at large -- in an increasingly energetic campaign to get a bill passed by the end of his first year in office.
AMA insiders shouldn't have been surprised by Obama's upfront refusal to consider malpractice caps.
The group couldn't get that idea passed by a Republican Congress and president a few years ago. Some states have such curbs, but anyone who can count votes knows the chances for national limits are slim to none with Democrats in charge of Congress.
Instead, Obama left the door open to some kind of compromise on malpractice.
The president said he's willing to explore alternatives to taking doctors to court. In the past, he supported special programs in which hospitals and doctors are encouraged to admit mistakes, correct them and offer compensation. Studies have shown the approach can work, because doctors' refusal to acknowledge mistakes is one reason many families file suit.
Doctors have special reasons to be wary of the president's plans to overhaul the health-care system.
Not long ago, doctors' decisions were rarely questioned. Now they are being blamed for a big part of the wasteful spending in the nation's $2.5 trillion health-care system. Studies have shown that as much as 30 cents of the U.S. health-care dollar may be going for tests and procedures that are of little or no value to patients.
The Obama administration has cited such findings as evidence that the system is broken. Since doctors are the ones responsible for ordering tests and procedures, health-care costs cannot be brought under control unless they change their decision-making habits.
"Change is scary," said Dartmouth University's Dr. Elliott Fisher, a doctor turned costs researcher. "I think there is a fear of loss of autonomy, that someone is going to tell you what to do." Fisher collaborated on research that showed large differences in health-care spending around the country.
But Obama did not blame the doctors. Instead, he tried to woo them, much as he has done with recalcitrant foreign leaders.
"It's the equivalent of international diplomacy. He's got to make them feel like it's possible to have dialogue about what the future looks like," Blendon said. "I think he's starting out with the AMA, but before the summer's over he's going to reach out to a lot of the other groups."
Obama assured the doctors that his plan would provide them with objective information on what treatments work best, with new computerized tools to better manage their patient case loads, and with support for harried solo practitioners to form networks.
He promised that Washington would not dictate clinical decisions. And he asked the doctors to imagine a world in which nearly every patient has insurance coverage and they can devote their full attention to the practice of medicine.
"You did not enter this profession to be bean-counters and paper-pushers," Obama said. "You entered this profession to be healers -- and that's what our health-care system should let you be."
That line got him an ovation.