AMA: Closing the uninsured gap hinges on personal coverage

Chicago -- When it comes to tackling the growing uninsured problem in the United States, the American Medical Association says policy-makers need to use both carrots and sticks.

In a major policy move for the Association, the AMA for the first time voted to support a requirement that people with sufficient means obtain a minimum level of preventive and catastrophic health care coverage. The requirement would start with individuals and families earning greater than 500% of the federal poverty level and would expand to the rest of the nation once sufficient federal tax credits or other subsidies are in place to help out with the purchase.

Under the AMA plan, the government would use the tax code to achieve compliance, possibly by handing out significant tax penalties to people who choose not to follow the directive.

For some physicians, such personal responsibility in health care can't come soon enough.

"This country is not going to tolerate the continued rise of the uninsured, and there must be some mechanism that we can fall to that will address this issue," said Bohn Allen, MD, a general surgeon and delegate from Texas. "One of them is individual responsibility, and I don't think that's an unreasonable thing to ask."

Requiring people to take responsibility for their preventive care and to plan for unforeseen medical emergencies when they can afford to do so will have a major effect on the health care system, said AMA Trustee Ardis Hoven, MD.

"Americans will be healthier because they will get the care they need when they need it," Dr. Hoven said. "The societal benefits of having more people insured, leading healthier lives, would be enormous."

Dr. Hoven and other physicians at the AMA Annual Meeting last month said the new policy adds a key element to the Association's comprehensive proposal for addressing the uninsured problem.

The Association already supports tax credits inversely related to income that individuals and families can use to purchase insurance, new options that allow people to own their own health insurance, and changes in market regulations to make it easier for people to find and afford the coverage they need.

This latest piece of the puzzle would prompt people who do not contribute to the system now to do so in the future, supporters said. Although some people with adequate financial means voluntarily forgo insurance coverage and pay out of pocket for health care when they need it, such an attitude ignores the fact that everybody has a limit, Dr. Hoven said. A victim of a car crash who sustains major head trauma, for instance, soon can outstrip any means that he or she has to pay, she said.

"In the days past, we cost-shifted expenses to another entity," she said. "But there is no more elasticity in the system to allow for that cost shifting to occur."

Mandate or choice?

AMA trustees and delegates supporting the resolution said it was not a mandate because failure to comply doesn't carry the threat of criminal penalties. The plan could result in noncompliant people over 500% of the poverty line being responsible come each April for a tax bill that is thousands of dollars higher than it normally would be.

Some physicians, though, said the introduction of tax penalties would cause a major public backlash against the physicians who supported them. Even if the purchase of health coverage remained technically voluntary, many people would view the proposal as a mandate because of the tax consequences for making a personal choice not to buy coverage, these critics said.

"The AMA is going to be about as popular as a porcupine in a balloon factory," said Joseph Bailey, MD, a rheumatologist and Georgia delegate.

Several delegates warned that the policy would punish people with pre-existing health conditions who are unable to obtain coverage even though they are in a higher income range. For 2006, five times the poverty line puts an individual's income at $49,000 per year and a family of four at $100,000.

AMA trustees noted that targeting this segment of the population would affect only slightly more than 5 million individuals out of the roughly 46 million uninsured people in the United States. Doctors said the societal benefits of insuring this population to start and then working down the income range as time went on would far outweigh the relatively few people who would be adversely affected.

"Money saved would be available to support the health care safety net, which would lead to fewer costs associated with treating the uninsured," said Ronald Bangasser, MD, a family physician and California delegate.

Fears of a single payer

The most vocal opposition to the new AMA policy came from physicians who said using the tax system to achieve compliance with the personal responsibility requirement would essentially hand the keys to the health care system over to the federal government.

"The imposition of individual mandates will definitely start a slow and steady spiral toward socialized medicine," said David McKalip, MD, a neurological surgeon and alternate delegate from Florida. "Make no mistake about it; what you're doing here today will result in a single-payer system."

Some delegates unsuccessfully attempted to scrap the policy and adopt a substitute that called for first observing how individual insurance requirements worked on the state level before backing it on a broader scale.

Massachusetts recently enacted legislation incorporating a personal requirement, and several other states are considering versions of their own.

At least one physician predicted that doctors would not like what they saw. "Do you honestly believe that what we suffer in medicine today is too little involvement of the federal government?" asked Richard Warner, MD, a psychiatrist and alternate delegate from Kansas.

Supporters, however, countered that sitting back to see what happens, not prodding people to take more control over their care, would lead to a health system with more government control. "It is actually the status quo that is the road to socialized medicine," said Robert Hertzka, MD, an anesthesiologist and delegate from California.

Dr. Hoven noted that the AMA policy intentionally left many details up in the air to enable productive debate on personal responsibility. No matter the mixture of carrots and sticks that policy-makers decide to use or the means with which they use them, the Association will be ready to contribute, she said.