When the American Medical Association threw its support behind the House health care overhaul, Democrats gleefully seized on the backing by the doctors lobby as akin to nabbing the Good Housekeeping Seal of Approval.

But the endorsement masked deep divisions within the medical community, where parochial concerns and broader ideological differences remain over how health care reform should be accomplished.

The inability of medical professionals to speak with one voice is not surprising given the independent nature of doctors, say physicians who serve in Congress.

“It is pretty typical for doctors to be all over the place,— said Rep. Michael Burgess (R-Texas), an obstetrician. “We don’t function well as a group.—

Already, a number of state medical affiliates have bucked the AMA — an umbrella group that represents regional, national and specialty interests — by opposing the House product for fear it will increase their Medicaid patient burden and prevent them from operating physician-owned hospitals.

Surgeons and other specialists have their own beefs with the legislation, which they view as tilted toward primary care physicians. Plastic surgeons are livid at a proposal in the Senate plan that would slap a 5 percent tax on elective cosmetic surgery. And some conservative doctors vehemently oppose what they regard as increased government interference as epitomized by the public insurance option.

But others, including family physicians and nurses, have applauded legislation that calls for bolstering primary care and health care accessibility.

Although Burgess is a member of the AMA, he opposed the House health care bill, which he said did not deal with Medicare payment reform and barely addressed the medical liability issue.

‘A House Divided’

Burgess complained the Democrats had succeeded in pitting the specialists against the primary care physicians.

“Part of the Democratic strategy was to make us a house divided,— he said.

Rep. Jim McDermott (D-Wash.), a psychiatrist, agreed that consensus is difficult to come by in the medical community.

“It is hard to find anybody who you can say is the voice of medicine,— said McDermott, who does not belong to the AMA but is a member of the American Psychiatric Association.

The liberal Congressman said that over the years the AMA’s dominance has been chipped away by the proliferation of specialists groups.

Nevertheless, McDermott, who voted for the House health care bill, said the AMA is better positioned to take the long-term view than specialty groups, which he noted are focused on how legislation would immediately affect their practices.

The disputes over the direction of health care boiled over at a meeting earlier this month of the AMA’s House of Delegates in Houston when a dissident faction unsuccessfully sought to persuade the association to back away from its support of the House plan.

“What we see in these bills is the government taking over more and more control,— said Donald Palmisano, a New Orleans physician and past president of the AMA, who was one of the leaders of the dissenting doctors.

AMA President J. James Rohack, a Texas cardiologist, said the debate within the medical community shows the “emotional aspect of health care.— He said doctors’ views are shaped by their geography and differing practices and that medical professionals can “look at data and interpret it differently.—

Nevertheless, Rohack said the AMA has strived to come up with a consensus to move the health care debate forward.

“We’ve got to do something,— he said.

Rohack noted that the AMA has a membership of 250,000 out of more than 800,000 physicians nationally. The association has lost and gained members since its endorsement, he said.

Public Support

While the AMA clearly is not the lone voice for doctors on Capitol Hill, it still has a formidable presence, spending $12.1 million on lobbying in the first three quarters of this year. That is almost $10 million more than the lobbying expenditures for the next-highest-spending doctors group, the American Academy of Family Physicians.

And the American Academy of Family Physicians turns out to be one of the AMA’s allies on reform.

The academy’s president, Lori Heim, said her group supported the public option as long as it met criteria including that the government insurance plan not be tied to Medicare reimbursement rates.

“We need to focus on what is good for our patients,— she said. “Is it perfect? No. But to walk away from it now I think is irresponsible.—

The American Nurses Association has also thrown its weight behind the House bill, which resulted in a thank-you call from President Barack Obama to the group’s president, Rebecca Patton, on the night of the House vote.

Rose Gonzalez, director of government relations for the nurses, said her association supports the public option.

“We believe health care is a human right, not a privilege,— she said.

Other medical groups have been far less enthusiastic about Democratic efforts.

“Unfortunately, as it is constructed this bill goes far beyond what is necessary to fix what is broken with our health care system,— Troy Tippett, president of the American Association of Neurological Surgeons, said in a statement opposing the House bill.

Aside from concerns about the public option and the high price tag of the bill, the surgeons singled out provisions regarding physician residencies that they said would hurt the work force of their specialties.

Heim, president of the family physicians, defended the focus on training primary care physicians, saying that currently the doctor work-force ratio is lopsided in favor of specialists, who comprise 70 percent of all doctors.

Opposition On Call

The Medical Society of New Jersey said it was particularly worried about the proposed expansion of Medicaid because New Jersey has one of the lowest Medicaid reimbursement rates in the country.

“While it is encouraging to see some effort to adequately fund primary care for those relying on Medicaid, swelling the ranks of beneficiaries in New Jersey will only exacerbate the challenges facing our specialists and the hospitals they work in,— Joseph Reichman, president of the New Jersey group, said in a written statement.

Other associations, including those in Ohio and Kansas, cited concerns with restrictions placed on physician-owned hospitals. These facilities have come under fire from some lawmakers who complain about doctors unduly profiting by referring patients to facilities they have a financial interest in.

The Medical Association of Georgia, which has joined with seven other state and national specialty societies to oppose the health care bills, has been among the most vociferous opponents.

The group cited increased federal regulations, potentially ballooning costs, the lack of medical liability reform and opposition to the public option as reasons for its opposition.

“I don’t believe the AMA position represents a majority of practicing physicians in the United States,— said Todd Williamson, a neurologist and past president of the Medical Association of Georgia.