As large clocks around the office counted down to Election Day last year, leading physicians ditched their business meeting and marched downstairs to stuff envelopes with campaign pamphlets in a makeshift war room at the California Medical Association’s Sacramento headquarters.
No issue confronting voters threatened the pocketbooks and political prestige of physicians more than Proposition 46, the latest turn in the doctors’ epic battle with trial attorneys over a limit on medical malpractice awards. Polls showed the measure foundering, as physicians and allied insurance companies poured tens of millions into the campaign. Yet the doctors weren’t taking chances.
For Dustin Corcoran, the swaggering chief executive of the medical association, the race was the culmination of years of preparation. And as chair of the opposition campaign, Corcoran stressed to his young staff the fleeting nature of political races.
“There’s a day that it ends,” he recalled telling them. “And nothing you can do the day after that is going to change the outcome of what just happened.”
The doctors’ campaign, choreographed by Democratic consultant Gale Kaufman, won in a rout. As an encore, the CMA was instrumental in two of this year’s biggest legislative fights: vaccines and doctor-assisted death.
Now, it’s preparing for the next showdown, a $2-per-pack tax on cigarettes aiming for next year’s ballot, with some of the proceeds going to boost the reimbursement rates for doctors who take Medi-Cal patients. Tobacco companies are again readying to spend heavily to ensure its defeat.
“Tobacco is really good at running a ‘shiny object’ campaign – almost always pointing to something unrelated and minor in the grand scheme of things,” Corcoran said. “In this campaign, tobacco is going to face the strongest, most organized and well-funded effort that’s ever been mounted against them.”
Founded in 1856 as the Medical Society of California, the powerful association functions as a trade group for more than 40,000 doctors in all modes of practice. In the early days, the physicians sought to differentiate themselves from “irregular” members of the profession, or quacks.
The modern CMA, operating in the burgeoning health care industry, is guided by well-connected, politically savvy employees who help steer millions of dollars through the lobbying and campaign systems to advocate for the interests of doctors. Admirers say CMA attacks and overwhelms issues with manpower and money. But its elevated stature and shifting priorities sometimes make the group a target.
Jamie Court, the president of Consumer Watchdog and proponent of last year’s health rate-regulation measure opposed by CMA, accused it of selling out on its principles, and dismissed it as a “go-along to get-along country club organization that lacks the fortitude to go after the insurers” over patients’ rights.
“They are everywhere in these battles because all of these unpopular industries want to stand behind the white coat,” Court said. “And the medical association will rent out that coat cheaply to anyone in the medical industry who wants it.”
The CMA’s staff had long been characterized by its buttoned-up, conservative cast of characters. A turning point came with the hiring of Steven M. Thompson as vice president of government relations in 1992. A brilliant mind who helped shape health policy, Thompson had been chief of staff to former Assembly Speaker Willie Brown.
In 1998, after reading a Brown biography, Corcoran knew he wanted to work under Thompson, a fellow Democrat. In his first position at the CMA, Corcoran raised money for its political action committee. He looked on as Thompson dealt with the board and executive committee, and sat in when he made phone calls. “I was probably a pest at times because I would just sit and listen,” Corcoran said.
When he made junior lobbyist, Corcoran’s youth gave him an edge with legislative staff, while Thompson relied on his tight relationships with their bosses. Their arrangement ended in 2004, when Thompson died of cancer at 62. His passing devastated the CMA, which struggled with declining membership.
Meanwhile, the composition and focus of its doctors evolved. Since 2006, its percentage of solo and small-group practices with five or fewer physicians dropped from roughly 40 percent to about 22 percent. Large practices of 1,000 or more doctors increased to 35 percent of the organization from 20 percent.
“For a lot of years, they were lost in the middle trying to determine whether they represented the old-school doctors or the future of medicine,” said Charles Bacchi, president and chief executive of the California Association of Health Plans. “Any organization whose membership is dwindling has to figure out how to change that. One way to do it is to look at where the growth in the physician community was happening, and a lot of that is happening through the large groups.”
After leading its lobbying team, Corcoran was promoted to CEO in 2010. He hired new talent and helped forge what employees say is a collaborative culture at the association, which has a staff of about 70 and annual operating budget of $23 million. Membership rebounded as Corcoran kept focused on protecting the Medical Injury Compensation Reform Act of 1975. It established the $250,000 cap on pain and suffering damages in medical malpractice cases. Increasing the limit, which the attorneys view as outmoded and arbitrary, was the focus of Proposition 46.
Some lawyers believe the campaign shouldn’t have occurred. They maintain Corcoran and his medical industry allies abruptly walked away from a deal that would have raised the cap to $500,000, with no cost-of-living adjustment. Lea-Ann Tratten, political director for the Consumer Attorneys of California, said CMA expressed initial interest, then rejected the idea as the deadline to file signatures to place the matter on the ballot was about to expire.
Corcoran said there never was an agreement in place.
CMA officials also reject claims of coziness with groups such as the hospitals and health plans, saying broader policy approaches are thoroughly deliberated and adopted by doctors. Their political influence is in part obtained the old-fashioned way, through lobbying elected leaders – and helping them get elected.
In the past five years, CMA spent about $11.1 million on candidates and causes. Sen. Joel Anderson, R-Alpine, said the CMA is skilled at cultivating candidates at the early stages, dispatching local physicians to spend time with them before elections to discuss their issues. “It’s not just a faceless group that comes in when they need things,” Anderson said, adding that they often make the best case for both sides of an issue.
“As a result, when their opponent comes in to lobby you, (the CMA) has really kind of stolen the thunder because there is rarely anything new,” he said. “They are not presenting these things in a vacuum. That builds trust.”
Since 2009, the CMA has spent $11.4 million on lobbying, an average of $437,000 per quarter. By comparison, the California Hospital Association spent an average of $870,000 a quarter in that time, while the California Dental Association paid out $168,000 a quarter. Recurring CMA skirmishes at the Capitol over scope of practice have seen the doctors defend their turf against encroaching optometrists, podiatrists and chiropractors. Corcoran, who favors well-tailored suits and carries himself with the kind of posture his doctors would be proud of, led high-caliber teams bending the ears of lawmakers.
“Dustin has a lot of confidence and that is apparent in how they conduct themselves,” said Tratten, of the lawyers’ group.
The CMA’s tactics can test relationships. Last month, in the waning hours of the legislative session, the medical association sent an urgent appeal to labor leaders on union-supported Assembly Bill 533, which aimed to sort out who should pay unexpected medical charges from health providers outside a patient’s network. The CMA’s president, Dr. Luther Cobb, wrote, “California’s doctors are workers, too.”
“Like you and your members, they spend years learning their trade and take tremendous pride in a job well done.” Cobb later added, “This anti-worker bill is a huge giveaway to health insurers.”
Barry Broad, a lobbyist representing the California Teamsters, said it angered some unions.
“That bill was a basic consumer bill,” he said. “So the notion they would build it into some self-righteous thing upset a lot of people in labor.”
The push revealed that the financial interests of doctors don’t always align with the interests of patients, said Anthony Wright, executive director of Health Access.
“When the CMA is embodying that public health voice, they can be very powerful,” Wright said. “But I think it’s also appropriate that they are scrutinized when they are advocating for just the self-interest of doctors.”
The CMA’s lobbying and political shops are headed by Janus Norman, who worked for the American Federation of State, County and Municipal Employees under longtime lobbyist Willie Pelote. Norman stressed that the CMA is committed to working out a solution to surprise billing. AB 533 was a bad bill that needed to fail, he said.
For all the time its staff spent on intricate industry measures, two blockbuster bills in which the CMA had an outsized role dealt with assisted death and public health.
The mandatory vaccine measure was supported by the CMA and co-authored by Sen. Richard Pan, a Sacramento Democrat who once sat on its board. He said the association’s stewardship over Senate Bill 277 demonstrated its commitment to public health. “Certainly not part of the CMA agenda this year was doing a big vaccination bill,” Pan said.
“While I think there is strong support among the membership for immunizations, that’s because it’s a good public health measure. It’s certainly not for the personal benefit of physicians.”
There was a darker side to the debate. In May, the CMA’s attorneys sent a warning letter to an official with the California Chiropractic Association that they believe encouraged opponents of the bill to stalk lobbyists for the legislation. Threats found their way to social media. Norman recalled sitting down his family and telling them to speak up if anyone suspicious was following them. “It was rough,” he said.
Most observers believe the assisted-death bill, also signed by Gov. Jerry Brown, would not have advanced if the CMA had remained opposed, as it had for decades. Sensing the issue would return to the Capitol this year, Dr. Ted Mazer, the speaker of the house of delegates, said physicians pored over the question. Ultimately, they settled on neutrality. On the bill itself, they elected to remain neutral only after the original authors of what became AB X2-15 agreed to limit their liability and provide other safeguards.
The CMA could have a stake in as many as five ballot initiatives in addition to the cigarette tax next year. Its 2011 white paper, which recommended regulating recreational marijuana similar to alcohol and tobacco, and its close relationship with Democratic Lt. Gov. Gavin Newsom, could set the stage for the CMA to back a pot legalization push. Newsom spoke at a CMA conference this year in Los Angeles.
Mazer said he and his wife never favored pot legalization, and didn’t expect to be moved. Newsom said it should not become a tax bonanza, and warned about keeping it away from children, Mazer said.
“After listening to (Newsom) talk, we kind of looked at each other and went, ‘If you can cover the things he’s worried about, it’s not so bad.’ ”
It’s this recurring ability to shape policy that keeps Corcoran engaged. In his seventeenth year at CMA, he said he’s constantly refining the organization, even bringing in an expert on workplace relationships to help employees develop.
“I don’t want people to ever be apologetic about working on behalf of doctors, or for CMA. I want them to be full of pride,” Corcoran said. “It is rare for people in the political world to be able to represent a really noble cause and a noble profession and at the same time have a lot of influence.”