I write today's blog from the back row of the American Medical Association's House of Delegates meeting, where the main topic of debate is whether the House will back its own elected Board of Trustees' decision to support H.R. 3962, the Affordable Health Care for America Act of 2009. The House of Delegates is considering resolutions that would either force the AMA to withdraw support for the bill and/or set a list of non-negotiable set of pre-conditions for the AMA to continue to support health reform. Yesterday, I sat through over eight hours of debate in front of a "reference committee" of House of Delegates members charged with hearing testimony and then drafting recommendations on the resolutions introduced by state and national medical specialty societies. The vote on the reference committee recommendations will take place this afternoon or evening.
As I've listened to the debate here, and also Saturday's debate in the U.S. House of Representatives, the image of tap-dancing through a minefield keeps popping into my head. To get a narrow majority to vote to pass H.R. 3962, Speaker Nancy Pelosi had to step around a series of political minefields, any one of which could have blown the bill apart. As reported in the Washington Post, the decision by Pelosi to allow a vote on an amendment to preclude federally-subsidized health plans from offering coverage of abortion was necessary to win the support of "pro-life" Democrats, but "pro-choice" advocates in both the House and Senate are vowing to block a final bill if it includes the same prohibition. Abortion, like it so often is in American politics, may end up being the single biggest minefield, because it is not suitable for "split the differences" compromises used to overcome other divisions.
The AMA is tap-dancing through its own minefields. If the delegates vote to overturn the organization's support for H.R. 3962, it could well paralyze the ability of its own Board of Trustees to continue to negotiate for its members, since the administration and Congress will lose confidence in the AMA's leadership to deliver. Yet there is a very vocal group of conservatives within the AMA House of Delegates who oppose H.R. 3962 on deeply held philosophical, political and ideological grounds, and they argue that the AMA will lose members if it does not change course.
There are many other delegates who believe with equal fervor that the AMA Board of Trustees did the right thing, and that the AMA stands to lose members if it reverses course. There are delegates who believe it is unwise for the AMA to reconsider its support for H.R. 3962, even if some of them have their own misgivings about the bill. They want the House of Delegates to set pre-conditions, or at the very least a list of top priorities and concerns, to guide future decisions by the Board of Trustees. The reference committee attempts to tip-toe through the minefield by affirming the House of Delegate's support for health reform in accord with established policies, even as it expresses "strong concerns about inclusion of" several provisions in health care reform legislation that would reduce payments to physicians who do not report on quality measures, reduce payments to higher resource use physicians, redistribute Medicare payments among physicians based on outcomes, quality, and risk-adjustment factors "that currently do not exist," and Medicare payment cuts for all physician services to partially offset bonuses for primary care services. (Interestingly, these provisions come from the Senate Finance Committee's version of the bill, not H.R. 3962.) I expect though, that efforts will be made today by conservative members of the House to turn these concerns and other issues into non-negotiable pre-conditions for continued support by the AMA and/or to substitute the original resolutions to reverse support for H.R. 3962.
The ACP, for its part, believes that H.R. 3962 advances important long-held policy objectives. (Our website has just been updated to provide a detailed list of answers to frequent questions about the ACP's views.) Our delegation to the AMA believes it would be a huge mistake for the House of Delegates to force the AMA to either withdraw support for H.R. 3962 or set "my way or the highway" pre-conditions, some of which are neither desirable nor achievable, which effectively would result in the AMA coming out against the current health reform effort.
No matter how the vote goes today in the House of Delegates, the AMA's slogan of "Together, we are stronger" does not reflect today's reality. Organized medicine will continue to be divided on health reform, reflecting the deep divisions among physicians on the role of government in health care, just as the close vote in the House of Representatives reflects the deep divisions on the same among the American people.
Today's question: What would you do if you were the AMA?