If Congress finally manages to solve the crisis of U.S. health care, it will have something to do with the work of a tall, silver-haired Texan who splits his time between Washington and his home on a sprawling ranch.

J. James Rohack, a Bryan cardiologist, has spent a lifetime at the intersection of medicine and health care policy. Last week, he became president of the American Medical Association, just as Congress ramps up efforts to overhaul the $2.6 trillion health care system and provide coverage to tens of millions of uninsured people.

Like many health advocates, Rohack, 54, preaches that the moment is right for reform. But the AMA, which spent nearly $20 million to lobby Washington last year, has long resisted federal involvement in medicine, dating to President Lyndon Johnson's creation of Medicare in 1965.

It has already laid down markers that it warns Congress not to cross, including an expansion of Medicare or a mandate that physicians participate in a new government-run insurance program.

"If the bills that come out don't allow choice," Rohack said, "that's not something that is American or acceptable.

"You should always have the ability to decide, do you want to get on public transportation or do you want to drive your car," he added. "I'm sorry – we're still Texans."

Anxiety

The AMA's anxiety over health reform was on display last week when President Barack Obama visited the group's annual meeting and urged its members to support a new public insurance plan.

AMA physicians spent several days parsing a resolution that initially called for the group to oppose a "public option," which many think is code for government-run health care. Many doctors complain bitterly that Medicare and Medicaid, today's government-run insurance programs, severely underpay for their services.

The group eventually settled on supporting "health system reform," provided it retains a place for private insurers and allows physicians to contract privately with patients.

"There is certainly a group of people that are mistrustful of the government, and anything having to do with the government is therefore bad," said Lori Heim, president-elect of the American Academy of Family Physicians, which supports a public plan.

"What you are hearing is the concern over their pay – and they haven't been convinced the benefit for the patient outweighs that," she said.

No repeat of '65

At his inaugural ceremony in Chicago this week, Rohack struck a more altruistic tone. He said the AMA was "ready to fully embrace" the cause of universal coverage.

"Our American capitalist system has always secured a higher level of medical care for those who succeeded, compared to those who fell by the wayside," he said. "In the wealthiest, most technologically advanced society in the history of the world – that is unacceptable."

But repairing that inequity will require a political settlement between powerful groups that have usually feuded over how to fund coverage for the 47 million Americans who lack health insurance.

It will also require some hard choices about how to cut skyrocketing health care costs, savings that could be put toward subsidizing coverage. Health care costs are expected to nearly double, to $4.3 trillion, by 2017, according to the Congressional Budget Office.

But physicians are nervous about the shape reductions will take. They already lobby Washington annually to stave off steep cuts in Medicare fees that are mandated as part of a savings formula Congress passed in 1997.

So far, Rohack and the AMA have stressed their cooperation with the White House. The group appears motivated by the fact that patients are unhappy with the current system and a concern they could be viewed as blocking reform.

"We would be making a mistake as an institution if we did now what we did in 1965," said Steven Kanig, a New Mexico nephrologist and member of the AMA's House of Delegates, its policymaking body. "We have been tarred by that label of being opposed to Medicare for the last 45 years."

On Friday, House Democratic leaders unveiled a 850-page "discussion draft" of health legislation, which their committees will begin considering this week. It includes a proposal for a new public plan that wouldn't be subsidized by taxpayers.

The AMA has said it doesn't think a new public plan "is the best way to expand health insurance coverage." An AMA spokeswoman said Friday the group wasn't prepared to comment on the House bill.

The bill also reforms the savings formula opposed by the AMA.

"There is a good bit in here for the AMA," said U.S. Rep. Pete Stark of California, chairman of the House Ways and Means health subcommittee. "It's the best improvement they've had in their payment structure for 15 years. I would think they'd like to keep it."

Other lawmakers suggested Rohack should feel no pressure to cut a deal if the legislation could hurt his members.

Rep. Michael Burgess, a Lewisville obstetrician who was elected to Congress in 2002, said the AMA maintains "significant weight" in Congress, particularly among lawmakers who aren't deeply familiar with the profession.

"Doctors have an enormous amount of equity when dealing with the public," said Burgess, a Republican. "They don't need any luster from the Congress or the White House."

For Rohack, the timing of the reform effort is felicitous. Physicians can spend decades in so-called organized medicine – the professional associations – and never have the opportunity to change the system for the better.

"The AMA has been about the business of trying to improve health care for all Americans for over 150 years, but for the most part that is piecemeal, attacking a problem or an issue one at a time," said Lonnie Bristow, who served as AMA chairman during the Clinton health reform effort.

UTEP grad

A native of East Rochester, N.Y., Rohack moved to Texas to attend the University of Texas at El Paso, from which he graduated in 1976.

Rohack got involved in the AMA shortly after graduating from the University of Texas Medical Branch in 1980. Beginning work as a cardiology resident in Galveston, he ran for a Texas seat in the House of Delegates.

"There was a designated spot for a medical student or resident," said Jon Hornaday, a former top aide to the Texas delegates. "Dr. Rohack did not run for a resident spot. He ran for one of the regular positions – and he won. This was sort of unheard of."

After his residency, Rohack took a joint appointment that allowed him to teach at the Texas A&M Health Science Center and practice at Temple-based Scott & White Hospital.

With hospitals and clinics spread over 25,000 square miles of central Texas, Scott & White operates on a model similar to Pennsylvania's Geisinger Health System and Utah's Intermountain Healthcare.

Those large, integrated institutions were pioneers in the effort to use data to measure the consistency and quality of care. Top Democrats managing health care reform – including Obama – regard them as models for American medicine.

In 1997, Rohack went to Intermountain for a monthlong boot camp to study quality of care measures. He learned from Brent James, a guru who preaches that best practices, or evidence-based guidelines, can improve the quality of medicine while eliminating unnecessary treatment.

"One thing I really feel in my gut about Jim is that he understands quality," said Frank J. Villamaria, Scott & White's medical director for quality, who went with Rohack to Intermountain. "Brent James often said if you improve quality, you reduce costs."

By most measures, Rohack's hospital performs better – and charges less – than other hospitals of its size in Texas.

It doesn't appear to soak Medicare, either. The average Medicare enrollee in Temple consumes about $7,015 per year in medical services, according to data compiled by the Dartmouth Atlas of Healthcare.

The average in Dallas is $10,103. In McAllen – a market whose high costs were chronicled by a New Yorker article that Obama has talked about – the average is $14,946.

"We can do things smarter and better," said Andrejs E. Avots-Avotins, chairman of Scott & White's board of directors and a longtime Rohack colleague. "With large group models, such as the one Dr. Rohack has been a part of, this could potentially be an answer to some of the issues we're facing."

Personal experiences

Having spent his entire career in Texas, where nearly 6 million people lack insurance, Rohack has personal experience with the problems that bedevil American health care.

Rohack also has a personal connection to what, in his Chicago speech, he called "the most vulnerable among us."

A daughter, Elisha, now an adult, was born with a severe mental disability and can't talk. She communicates "with her eyes," Rohack said, which requires family members to pay close attention.

His wife, Charli, turned their ranch in Bryan – a 23-acre spread with a lake that was once "a weekend poker place" for "a bunch of Bryan bankers" – into a wildlife rescue. She rehabilitates injured hawks, owls and other birds of prey.

Animals operate on "the natural, survival-of-the-fittest mechanism – if you are ill or injured, you are on your own," he said. "As human beings, we take care of those that are ill and injured. That is the difference."

Some of his ideas about how to prevent health problems also come from personal experience.

In his speech in Chicago this week, Rohack called for rules that protect patients from "making bad choices," including a mandate that all cars come with Breathalyzer devices.

Rohack didn't mention that he pleaded guilty to driving while intoxicated in Brazos County in 2006.

Rohack said he ran into trouble after drinking a Bloody Mary at a breakfast in January 2005. He didn't think he was intoxicated and decided to drive.

But that is precisely what many intoxicated drivers think, he said.

"I have used this to talk to medical students and others to say that all of us have to be aware we are not perfect," he said. "Sometimes we are under stress, and it's important to have a healthy lifestyle to prevent yourself from getting into trouble."

THE AMA'S PREFERENCES FOR HEALTH CARE OVERHAUL What the American Medical Association wants from health care reform:

•A tax on the value of employer-sponsored health benefits. The revenue would fund tax credits to buy insurance for individuals and families earning up to 500 percent of the federal poverty level ($110,000 for a family of four).

•Reform of Medicare payment guidelines, including repeal of a formula that requires steep cuts in physician fees and compensation for coordinating patient care with hospitals and specialists.

•Exemption from malpractice lawsuits if physicians show they followed medical best practices, also known as evidence-based guidelines.

•National standards that would extend Medicaid to all persons below the poverty line.

•Higher taxes on alcohol, high-sugar beverages such as sodas, and fatty foods.

What the AMA opposes:

•Any new government-run insurance program that would replace private insurance.

•Large cuts to Medicare and Medicaid reimbursements.


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