On his 23-acre ranch-turned-wildlife refuge in rural Texas, James Rohack and his wife delicately nurse injured falcons and other fierce raptors back to health.
Dr. Rohack, 54, will need that deft touch as he steers the Chicago-based American Medical Assn. through what likely will be the biggest overhaul of America's health system since the creation of Medicare in 1965. Sworn in as AMA president this month, he spent his first two weeks fending off criticism of the association's clumsy response to President Barack Obama's plan to expand health insurance coverage.
His challenge is to craft a strategy that protects the interests of doctors without appearing to obstruct the broader health care reform the public wants. A vain attempt to block reform would jeopardize other AMA goals and could further marginalize the group, which is losing influence as its membership wanes.
"The AMA doesn't want to be on the losing side of the health reform battle," says Aaron Carroll, director of Indiana University's Center for Health Policy and Professionalism Research. "That would limit their bargaining power on reimbursement rates and other big priorities. It's a tricky tightrope to walk."
Walking that tightrope will be a cardiologist who favors loud ties and stingray-hide cowboy boots. During nearly a decade on the AMA's board of trustees, including a 2004-05 stint as chairman, Dr. Rohack was a vocal critic of the managed-care industry. As president of Texas' medical society, he led lawsuits against Aetna Inc. and other national insurers over payment disputes. The insurers eventually settled.
Ironically, the AMA now is concerned that a public health insurance option, favored by Mr. Obama, would harm insurance companies. While insurers often vex doctors, they pay higher rates than government-run plans.
The AMA has a history of fighting federal involvement in medicine; it opposed Medicare and was a key force in blocking President Bill Clinton's healthcare overhaul 15 years ago. Its objections to the Obama proposal focus on the government insurance option.
Five hundred AMA delegates this month backed a resolution calling for "health system reform" but didn't mention a public insurance option. In earlier testimony to a Senate committee, the AMA said a public option isn't the best way to expand insurance coverage and reduce costs for non-disabled people under 65, and warned it could drive private insurers out of the market.
Dr. Rohack says the AMA is open to a public option, including allowing people without insurance to buy into the system that insures federal employees, although that could prove too expensive. It's also open to non-profit cooperatives that would provide health insurance in states or regions, a proposal that has gained traction in Congress in recent weeks.
He says the AMA is committed to working with the president and Congress to pass reforms that ensure health coverage for all Americans, a big step forward from its obstructionist past.
"That's an important evolution that the AMA has undergone, being viewed as a constructive partner and bringing together differing viewpoints," Dr. Rohack says.
The 162-year-old AMA represents 236,000 physicians, about a quarter of all U.S. doctors, down from around 70% in the 1960s. Still, it's the only group that represents doctors across all specialties and U.S. regions. Its support is viewed as important for any health plan to emerge from Congress.
The AMA's revenue slipped 2.6% last year, to $282 million, coinciding with a 2% drop in membership. Operating income was down 90%, to $2.5 million, though it was the ninth-straight year that the group finished in the black.
Dr. Rohack could have good reason to compromise on the public-plan issue. In a June 15 speech to AMA delegates in Chicago, Mr. Obama mentioned the importance of fixing a Medicare payment system that requires doctors to mount furious lobbying battles every year to stave off deep cuts. The formula, created in 1997, calls for a 21% cut to doctors in January. Congress has always stepped in to nix those cuts in the past, but the AMA wants a permanent fix. The House of Representatives' reform bill would provide it.
"We're hoping that our commitment to making sure patients have affordable health insurance and reducing costs will help in getting rid of that big barrier," Dr. Rohack says of the payment issue. He wouldn't say which is a higher priority: fixing the payment system or a public plan the AMA can live with.
Colleagues say Dr. Rohack is just the guy to negotiate such complicated horse-trading. He's firm but not dogmatic and able to absorb an unusual amount of detail on complex issues, says Susan Bailey, president-elect of the Texas Medical Assn.
"I've been attending meetings with him for 30 years, and he's always the most prepared person in the room," she says.
He also brings personal experience to the AMA's goal of universal health coverage. During his inaugural speech in Chicago, Dr. Rohack thanked his wife and adult daughter, who has a mental disability and is unable to speak.
"We need to make sure that our healthcare system works so that it doesn't forget the most vulnerable among us," he says.