The apparent defeat of the medical profession on the issue of extra-billing presents an anomaly, in light of the historical and comparative literature on the political power of medicine and the more general interest group literature regarding the disproportionate political influence of concentrated interests. On closer examination, the extra-billing episode suggests some modifications to theories of the political advantage of concentrated interests, but does not present a deviant case. It rather provides an example of the political vulnerability of concentrated interests on issues of broad symbolic appeal; it illustrates the ability of a concentrated group to use its traditional advantages in processes of negotiation and accommodation with policy-makers to achieve tangible and positional gains in compensation for symbolic losses; and (in the case of the conflict in Ontario) it demonstrates the susceptibility of such negotiations over symbolic values to problems of misperception, miscalculation and “face.” In longer-term perspective, moreover, the extra-billing issue is best understood as an episode of conflict in a long history of accommodation between medicine and the state under comprehensive medicare.