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).
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?