CHICAGO – The diversity of opinion within organized medicine got a full airing when delegates to the American Medical Association House of Delegates were asked to consider whether to maintain support of an individual mandate for health insurance.
While the 325-165 vote was overwhelmingly in favor of reaffirming that policy, it was preceded by hours of rancorous debate.
“It was a debate in which both sides who feel passionately about this question were able to be heard,” said Dr. Cecil Wilson, AMA president. “What is important to emphasize is fully two-thirds of the House said today our policy is good.”
Many delegates used the debate over the AMA policy as a surrogate for debate on the Affordable Care Act (ACA), while others viewed it as a platform for their dissatisfaction with the AMA's support of health reform.
While concerns about the ACA still linger, majority support of the individual mandate represents a growing progressive tide within the physician community, according to Dr. Stuart Cohen, delegate with the American Academy of Pediatrics. “While the minority is very vocal and extremely articulate, I think we're seeing a change in organized medicine based on changing employment trends and the needs, aspirations, and concerns of the more progressive, younger physicians,” Dr. Cohen told
Policy Evolution
As far back as 1998, AMA promoted the idea that individuals with financial means should buy health insurance.
That idea was formalized as organizational policy at the 2010 House of Delegates meeting; however, at that time, delegations from Kansas, District of Columbia, Florida, Georgia, and the American Society of General Surgeons (ASGS) dissented and offered a resolution to withdraw support for the mandate.
The 2010 House voted to refer the question to the Board of Trustees, which tasked the Council on Medical Service (COMS) to study the issue. This year, COMS issued a report stating that not only is individual mandate the best way to ensure wider insurance coverage, but also that there is no viable alternative.
The response was a slew of resolutions addressing all sides of the issue.
One coalition offered a resolution to encourage patient responsibility via tax incentives instead of via a mandate.
The Ohio delegation offered a resolution to support “free market solutions” to achieve universal access.
Conversely, a large coalition of primary care and specialty organizations – including the AAP – as well as state delegations offered a resolution to reaffirm AMA policy and expand it somewhat.
The main debate occurred over a 3-hour period in front of Reference Committee A.
Dr. Wilson reminded delegates that the organization's long-standing position backing the individual mandate reaches back to before the most recent health reform efforts. “During that intervening time, there has been no additional evidence to suggest that we have another alternative,” said Dr. Wilson, an internist from Winter Park, Fla. “I would suggest that our decision in the middle of the last decade was a good decision. I think the need to stay with it is even more so now,” he said.
Reaffirmation Despite Opposition
On June 20, a day after the Reference Committee debate, that panel brought its recommendation to the floor. The committee recommended that the House vote to reaffirm current policy and reject alternative resolutions
To accommodate more debate, House Speaker Andrew Gurman, a hand surgeon from Altoona, Pa., established a precedent. Delegates who wanted to express an opinion were asked to line up at microphones marked either “pro” or “con.”
Dr. Richard Warner of the Kansas delegation, at the con mic, offered a new amendment that called on the AMA to back states' rights. “No matter what the court does, I think there is going to remain division in the country and division in the AMA about the role of the individual mandate, so probably the best solution to that is to allow a mandate to exist as policy but in control of states rather than at the federal level,” said Dr. Warner, a psychiatrist from Overland Park.
Georgia delegate Dr. Michael Greene agreed. “I believe that each state working with the population it has, and the specific problems that it has, can craft a solution that works better for that state perhaps than the one next door.” He pointed to Massachusetts as an example where the state had determined what worked for its citizens.
But Dr. Melissa Garretson, a Ft. Worth, Tex., pediatrician and AAP delegate, said that while physicians might be angry about the AMA policy, “I have 700,000 uninsured pediatric patients in Texas who are angry, too. The evidence has shown that mandating insurance coverage gives us the highest percentage of insured individuals in this country,” she said.