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A map of North America surrounded by a stethoscope, medicine capsules and medical syringe symbolizes health care reform in the U.S. - 


Tess Vigeland: Rumors have been swirling for months in Washington about a split in the health insurance industry. It's not about who covers what. It's about who should represent the interests of huge insurance companies versus smaller and midsize ones on Capitol Hill.

Word from Kaiser Health News today is that the five largest are shopping around for their own PR firm. We asked Gregory Warner at the Marketplace health desk at WHYY in Philadelphia to parse it out for us.

Gregory Warner: Last year, the insurance lobbying group America's Health Insurance Plans quietly spent $86 million to oppose the health care law, while at the same time publicly supporting reform. Now the lobbying focus has changed. No longer about voting down the law.

Sheila Krumholz: It's influencing and tweaking implementation, and in some cases perhaps stalling implementation.

Sheila Krumholz directs the Center for Responsive Politics in Washington. As the strategy for lobbying has changed, a rift may have formed inside the lobbying group.

Ron Pollack: The interest that a smaller insurance company may have might well diverge with the interest of a larger insurance company.

Ron Pollack is executive director of Families USA, an advocacy organization for health care consumers. The insurers lobbying group declined to comment, while large insurers Cigna and Wellpoint did not return calls or e-mails.

Those large insurance companies, though, are looking to how states set the rules of the exchanges -- where those of us without insurance will have to buy it in 2014. Large insurers may want states to design those exchanges to reward efficiencies of scale in ways that keep smaller insurers out of the running.

JB Silvers: So this is a continuing drama.

JB Silvers teaches health care finance at Case Western Reserve University. He used to run a small insurance company. He says the interests of big insurers are clear.

Silvers: They're going to get 26 million more enrollees and they want to bargain now for better rules.

What was a fight over politics, may be turning into a fight for more customers.

In Philadelphia, I'm Gregory Warner for Marketplace.

Follow Gregory Warner at @radiogrego