If President Clinton achieves nothing else in the health-care debate, he is responsible for one medical breakthrough: peace between chiropractors and orthopedic surgeons.
They have fought bitterly for sovereignty over lower back pain since an Iowa healer straightened out a janitor 99 years ago, giving birth to chiropractic. But early this month, in a scene as dramatic as the Rose Garden "handshake" of Israeli and PLO leaders, Washington lobbyists for the two groups met across a conference table to join with other health professionals who want assured access to patients in HMO-style networks."I'm sitting there pinching myself," said Richard Miller, chief lobbyist for the American Chiropractic Association. "What . . . is going on?"
For legislation in dire search of a political consensus, the main health-care reform proposals united a remarkable number of disparate, often rival groups that put aside differences for a common interest: securing a strong place in any new health-care system.
Of course, the phenomenon worked both ways. For every patchwork of interests supporting change, one emerged to oppose it.
When the American Medical Association decided to make malpractice reform a priority, it reached out to insurers, with whom it otherwise clashes over standards for doctors participating in health-care networks. The AMA also brought in hospitals, which it battles separately over the right of physicians to collectively negotiate fees.
In the end, the malpractice coalition, called Health Care Liability Alliance grew to 25 members, including pharmaceutical interests and medical device manufacturers who all support a $250,000 cap on the noneconomic damages of medical malpractice suits.
But even so potent a combination as the HCLA came up with nothing in the main bills of the House and Senate, blitzed by a competiting bloc of trial lawyers and consumer groups.
"Just because we're big organizations doesn't mean we're guaranteed to win on every issue," said HCLA Chairman Martin J. Hatlie. "It gives you some sense of how important the other side was."
Most of the odd-couple alliances are inspired by common threats. The Big Three automakers and the United Auto Workers go to war over health benefits in every contract renegotiation. But when the Senate's "mainstream coalition" proposed a tax cap on benefits, labor and management joined to stop the initiative in its tracks.
But by far the biggest rapproachment involved the chiropractors. Their meeting included not only the orthopedic lobbyists, but officials of the AMA, co-recipients of a 1987 federal court order to stop plotting the elimination of chiropractors. Much of the medical community has long held that chiropractors, who specialize in spinal manipulation to relieve back problems and headaches and eschew the use of drugs or surgical procedures, are "quacks."
The order, in a lawsuit brought by the chiropractors, was intended to end decades of discrmination by orthopedists, who used to distribute "quack packs" to patients referred by chiropractors, according to Jerome McAndrews, a vice president of the chiropractic association. Along with other AMA members, the back surgeons lobbied state legislatures to stop licensing chiropractors.
Rivalry remains fierce among the 50,000 chiropractors and 15,000 orthopedists. But both groups recognize an even larger competitive threat in the HMO practice of limiting their customers to a set panel of doctors and regulating visits to specialists.
Working separately in the health-care fight, Miller's chiropractic association and the American Academy of Orthopaedic Surgeons each formed coalitions to keep open their channels to patients.
Miller was the first to suggest a truce after discussing mutual concerns with an AAOS lobbyist. Their opposition - an alliance of big insurers and HMOs - was especially strong in the Senate, and Miller knew of the political strength in numbers.
Assured of help from key senators, he called Nicholas Cavarocchi, head of the AAOS's office, and said, "We need to get together as many people as we can to" lobby for the right of HMO customers to seek treatment outside their networks.
The significance of the alliance was broadened by the marriage of two coalitions: Miller's group of nonphysician providers and Cavarocchi's medical specialists. Sitting around the same table were the lobbyists of other traditional rivals: psychologists and psychiatrists, optometrists and ophthalmologists, dermatologists and plastic surgeons.