Friday, June 24, 2011

Not your Grandfather’s AMA

I just came back from five days in Chicago, observing the American Medical Association's (AMA's) House of Delegates meeting. This year's meeting was one of the most fascinating and consequential that I’ve observed during thirty-some years of going to the AMA.

Fascinating, because the AMA had to come to grips with a deep split among its membership on continued support for the key tenets of the health reform law. Consequential, because the decisions by the AMA at this meeting would determine if it would remain a voice for continued implementation of the Affordable Care Act’s reforms to ensure that all Americans would have access to affordable health insurance, or join the camp of those seeking repeal.

The specific issue at stake was whether the AMA would rescind its long-standing support for the requirement that all Americans purchase health insurance, coupled with tax credit subsidies to help people buy coverage. Last November, a dissident ---and highly organized--- conservative faction of the AMA House of Delegates tried to get the organization to withdraw support for the mandate. Instead, the issue was referred back to the AMA's Council on Medical Service (CMS) for further study. The Council submitted a report for consideration at this week's meeting, recommending reaffirmation of AMA policy to support of the individual insurance requirement.

The dissident factions, led by the Kansas Medical Society and supported by about a half dozen state and specialty societies, countered the CMS report by introducing a resolution to replace support for the mandate with tax credits and other incentives to purchase health insurance.

The American College of Physicians (ACP) led the fight in favor of the individual insurance requirement, introducing its own resolution of support for the mandate. ACP's resolution was co-sponsored by 19 national and state medical societies, including several of the largest specialty societies in the United States.

The battle lines were drawn, and it was unclear which side would have the votes to prevail. Testimony on the competing resolutions and the CMS report was intense, highly polarized but generally respectful of the other side's motives and intentions. The dissidents argued that the individual mandate was an "unconstitutional" threat to liberty; proponents pointed out that the courts, not the AMA, will decide the legal issues, and that the AMA should speak to the health impact on patients if more of them end up uninsured.

The dissidents argued that there are less coercive ways to get everyone covered; proponents cited evidence that 16 million more people would go without coverage without the individual insurance requirements.

The dissidents argued that lack of health insurance does not guarantee access to care; ACP and other proponents countered that although health insurance by itself does not ensure access, there is compelling evidence that lack of health insurance results in people living sicker and dying younger. (See my post from last week on the consequences for patients if the individual insurance requirement is found to be unconstitutional).

You can get a good sense of the arguments made by both sides-- and of the extraordinary leadership role played by the ACP-- by reviewing the Tweets from me and others who watched the debate unfold.

Who won? Well' after several days of intense debate' the AMA decisively voted, by a 66% to 33% margin, to re-affirm support for the individual insurance requirement, preserving it as a key element of the AMA's overall plan to ensure universal access to affordable coverage. The margin of support among the delegates for staying the course was far greater than most of us anticipated going into the meeting. And, while the AMA will continue to seek changes in the ACA that are opposed to its policies, it will not join the camp of those who want to repeal it, lock, stock and barrel.

I wouldn’t necessarily argue that this vote shows a permanent shift to the left within the AMA, since many of the delegates who voted for the mandate based their vote on pragmatic considerations that an individual insurance requirement is the only way to ensure coverage for nearly all Americans while preserving private health insurance, not on their own personal political ideology. The AMA's elected leadership showed conviction and courage, and many of the delegates rallied around their leaders.

Yet this week's vote shows that although there remains a determined and very vocal minority of delegates at the AMA who hold a strong, anti-government ideology, they are now in the distinct minority, and physicians who believe that the federal government must guarantee access to affordable health insurance are in ascendancy. Following the AMA vote, some of the dissidents argue that conservatives should leave the AMA in droves, but a continued conservative exodus from the AMA will only further diminish their influence within the AMA House of Delegates.

But the real winners are the tens of millions of uninsured Americans who know that the nation's largest physician membership organization (yes, AMA is still the largest) remains on their side in fighting to ensure that everyone has access to affordable health insurance coverage.

Today’s questions: What is your reaction to the AMA's decision to stay the course on health coverage for all? And ACP's leadership at the AMA in helping to bring this about?


Steve Lucas said...

My understanding is that the AMA represents only about 17% of practicing physicians. If it were to loose those dissentient members it would be down to about 12%.

Hardly an overwhelming majority of the medical community.

Now about the bulk of its income coming from commercial activities including the continued use of the very billing codes it helps establish.

Steve Lucas

ryanjo said...

Well, since Bob has put his "Save the ACA" spin on the AMA meeting, let me take an opposing view.

The relevance of this AMA action is questionable, as is the relevance of the AMA itself. The organization has lost 5% of its membership, over 12,000 doctors in the past year, mostly established members paying $420/year. The AMA leadership admits that recent membership losses stem from dissatisfaction over AMA support for the ACA. The remaining 200,000-plus members are over a third medical students, residents and young MDs provided nearly free memberships, likely attracted by discounted education benefits and new practice assistance, rather than ideology. Even with the exit of disaffected members, one-third of AMA delegates opposed the AMA's continued ACA support, and (as Bob reports) many supporters voted along pragmatic and not ideologic lines. Together, this represents a huge proportion of its remaining loyal membership in opposition or limited support.

The AMA purports to represent American medicine, but is shunned by most American physicians, partially because it doesn't recognize that its effectiveness depends on representing the needs of all of its members. If the AMA used the assembly to issue a statement about the concerns that caused this challenge to its position, it would have made a valuable contribution. The action taken merely caused the 80% of us outside the AMA to shake our heads yet again at AMA bumbling.

The ACP leadership may benefit from reflecting on what happens to an organization that fails to represent all its membership.

Paul Rousseau said...

And this confirms why I am not a member of the AMA.

Harrison said...

The AMA may be doing the political math.
Doctors are moving away from being small business owners aligned with conservative groups like the Chamber of Commerce.
Instead young doctors are gravitating to employed relationships with large groups or with hospitals.
As employees their political interests change.
The NY Times did a piece on this not all that long ago.
Not an opinion piece.
One of those fact based pieces that the news media is going to have a harder and harder time to fund in the future.

Anyway -- The point I guess I'm getting to is that for every angry physician who disagrees with the AMA's position on the ACA, the AMA may stand to attract physicians who were traditionally opposed to the organization because they felt it was too conservative.

Just a thought.


Arvind said...

Harrison is probably correct with his numbers, but only people like Bob here find that the AMA actually has any relevance any more.

An interesting observation here in PA - the PA Medical Society (a subsidiary of the AMA) endorsed Sen. Toomey, who vowed to repeal the ACA). So much for the AMA's ethics and moral fabric! So, let the AMA RIP. If the ACP does not learn from this dissent, it too will become an irrelevant organization....

PCP said...

The AMA is in the process of committing suicide. They have certain monopolistic positions like their CPT coding manual and their control of the super secretive RUC, that keep them relevant, but they are for all intents and purposes an emperor without clothes and are very much acting like it.
Their loss of membership is astounding, I am unaware of very many physicians under 40 that are paying members of the AMA, mainly because they see no value to them in the representation of this organisation.

Harrison, one simple response to your dream of stable AMA membership............It ain't happening. The decline is inexorable and continuous.

I suspect we would have seen the emergence of viable alternative, were it not for the monopoly position granted the AMA by Gov't in the ways outlined above. As we are finding out now(and as Japan found out for the past 2 decades) Gov't can delay but not prevent the inevitable.

The worst part of the ACA (for me)is the de facto enforced conversion of Physicians from proud professionals/employers/small business owners to clock watching employees............Unions???? to come?

Harrison said...

I am not fond of the idea that physicians are moving to shift work.
But it is undeniable.
ER physicians have always identified with a place and not with a group of patients.
This is also true of anesthesia. And radiology.
Hospitalists allow primary care physicians to do shift work. And with hospitalists, outpatient physicians may have to manage patient panels, but they increasingly do this in a more detached way.
They are part of bigger groups, maybe as employees, and they have to be available and they have to make sure that patients assigned to them meet certain pay for performance criteria ... but they don't really identify with individual patients as much as they used to.
They won't go to see them in the hospital -- even out of curiosity.
They won't see them in a nursing home.
And home visits ... well now we have mobile doctors.

I dislike these trends.
But I could have said that all of this was happening to our profession before Barak Obama was elected. In fact the trends were clear before he was elected to the Senate from Illinois.
The ACA is not to blame.
It doesn't fix it. But nothing can or will.
It simply is.

The way that health care as a service industry moves into the future isn't something that can be centrally mandated.
The ACA cannot and will not do that.
Doctors will make choices about what they are willing to do and how much they will accept as payment for doing it.
Nurses will make similar decision.
And these decisions will match the demands of the health insurance industry, which will be driven by patient demand -- because that is where the money comes from.
Some of that money flows into the industry through tax revenues, but it is still generated by patients and in a very round about way, demands and payments and services rendered will all equilibrate.
The ACA may try to regulate some of this and it certainly helps to increase the number of patients -- but it will not shape the industry.

Only a program as profound as Medicare can shape the industry.
The ACA is not Medicare.

Which brings us back to Rep Ryan's proposal.
Now that proposal was and is profound in ways that the ACA couldn't dream of.