AMA House of Delegates

AMA meeting: AMA reaffirms stance in health system reform debate

The Association keeps its options open on public plan issue amid calls from some delegates to take a stand.

By Emily Berry — Posted June 29, 2009

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Addressing what has become the hottest flashpoint in this year's health system reform debate, the American Medical Association House of Delegates at its Annual Meeting in June renewed its existing reform policies rather than declare a position on whether lawmakers should establish a new national federal health insurance plan that would compete with private insurers.

Delegates agreed that the AMA should "support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice and universal access for patients." Both supporters and opponents of the public plan concept wanted the Association to take a definitive stand on the issue. But after AMA Immediate Past President Nancy H. Nielsen, MD, PhD, warned that such a move could handicap the organization as it tries to influence the health reform debate, delegates backed away from those resolutions.

Dr. Nielsen said the resolution that ultimately passed would allow her and AMA President J. James Rohack, MD, to keep the AMA engaged in the debate without restriction but with a clear directive to advocate for choice for both physicians and patients.


AMA Immediate Past President Nancy H. Nielsen, MD, PhD, warned delegates that taking a definitive stand on the health reform issue could handicap the organization as it tries to influence the debate.

The house's deliberations over health system reform, which for hours were focused solely on whether to support the public plan option, came on the heels of President Obama's address to the house in which he promoted the idea. In a speech that lasted nearly an hour, he laid out his case for reform, calling it the most important thing the government could do to help the nation's economy.

"I need your help, doctors, because to most Americans you are the health care system," Obama told delegates. "The fact is Americans -- and I include myself and Michelle and our kids in this -- we just do what you tell us to do. That's what we do. We listen to you, we trust you. And that's why I will listen to you and work with you to pursue reform that works for you."

He prompted a standing ovation by saying he wanted to give physicians some relief from medical liability pressures. But then he elicited the only negative response from the audience when he said he still does not support capping damages, because he feels caps "can be unfair to people who've been wrongfully harmed."

Obama, the first president since Ronald Reagan to address the AMA Annual Meeting, advocated for creating a health insurance exchange with a national government plan option. That element of his reform vision so far has been the most divisive in Washington, D.C., and it played the same way in the House of Delegates.

Obama tried to preempt physician fears about what a new public health insurance program would mean. "The public option is not your enemy -- it is your friend."


Speaking for the AMA Board of Trustees, outgoing Trustee Samantha Rosman, MD, urged delegates not to pass a resolution opposed to a public plan.

But opponents say a public plan would have an unfair advantage over private insurers that might be serving patients well. Some physicians worry that any new government entitlement inevitably would pay poorly and that doctor participation would become a mandate, whether official or de facto.

"One only has to look at Medicare to see that something offered up as an option may quickly become the only option," M. Todd Williamson, MD, Medical Assn. of Georgia's president, said during later floor debate.

Obama acknowledged that some doctors have reason to be skeptical.

"There's a sense out there among some, and perhaps some members who are gathered here today ... that as bad as our current system may be -- and it's pretty bad -- the devil we know is better than the devil we don't," he said. "I'm here to tell you I understand that fear. And I understand the cynicism. They're scars left over from past efforts at reform."

Obama also reiterated that he does not support a health system in which government is the only payer. "I'll be honest: There are countries where a single-payer system works pretty well. But I believe -- and I've taken some flak from members of my own party for this belief -- that it's important for our reform efforts to build on our traditions here in the United States. So when you hear the naysayers claim that I'm trying to bring about government-run health care, know this: They're not telling the truth."

Delegates debate position

When the issue of the public plan option reached the floor of the House of Delegates the next day, some delegates said it was too soon to officially oppose the idea. They urged fellow delegates to pass a resolution that would allow the AMA to negotiate with the Obama administration without presenting an ultimatum. Otherwise, the Association would run the risk of being excluded from the rest of the reform debate, they argued.

"If we draw this line in the sand, everyone else is going to go around that line and down the beach," said Mario Motta, MD, a cardiologist from Salem, Mass., and the Massachusetts Medical Society's president.

But some vocal critics said a public plan, at least one that looked or paid anything like Medicare, was in fact a deal-breaker in the reform debate. They wanted AMA leadership to communicate that to the White House.

Speaking for the AMA Board of Trustees, outgoing Trustee Samantha Rosman, MD, urged delegates not to pass a resolution opposed to a public plan. "We share your concerns about government health care," she said. "These are the same concerns we expressed to the Senate Finance Committee and the Obama administration. We told them it's not acceptable to compel physicians to participate or to tie reimbursement to Medicare rates. We know coverage does not equal access."

As the debate continued, more delegates argued that AMA leaders' ability to "remain at the table" as health reform is drafted was paramount.

Former AMA President Lonnie Bristow, MD, a specialist in occupational medicine from Walnut Creek, Calif., argued against an amendment that would have clarified what type of public plan option the AMA opposed.

"I would plead with this House of Delegates not to tie the hands of your Board of Trustees," he said. "Every time we have another 'not' in [the resolution] we are tying another knot."

Twice, delegates were close to finalizing resolutions taking a stand on the public plan issue when Dr. Nielsen stood up to address them and urge reconsideration. Both times, they rephrased the pending language, first to remove any mention of what the AMA opposes, and second, to replace the term "public option" with "health system reform."

After the final resolution was adopted, Dr. Nielsen thanked the delegates for keeping the AMA on its reform mission. "The message you have just sent is that we are going to build a bridge to a better future for our patients, and we will lead the change."

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Meeting notes: Legislative actions

Issue: Medicare's physician payment formula and temporary patches to scheduled pay cuts have produced low pay rates that diminish many doctors' ability to accept Medicare enrollees.
Proposed action: Offer principles for Medicare pay reform without endorsing one specific methodology; continue to advocate for reform of the Medicare payment system; push for improved, confidential data collection; support pilot programs that identify successful approaches to pay reform; support changes in antitrust law that would enhance care coordination; and work to ensure any bundled pay systems do not result in hospital-controlled physician payments. [Adopted]

Issue: Organized medicine wants to see medical liability reform included in health system reform.
Proposed action: Pursue effective medical liability reforms as part of federal comprehensive health system reform efforts. Discuss with federal policymakers a wide range of traditional and alternative measures that will not undercut existing state reforms. Such options might include pilot programs on alternative dispute resolution mechanisms, including health courts. [Adopted]

Issue: Doctors seek alternatives to the medical liability system.
Proposed action: A report calls for further research of Michigan's patient compensation system, a no-fault liability system, before determining if it can be a model alternative for other states unable to achieve traditional tort reform measures. While Michigan's program appears to provide certain patient safety benefits, the report called attention to potential unintended consequences, such as an influx of claims and onerous fees that could outweigh the cost of current medical liability insurance premiums. [Adopted]

Issue: A growing uninsured and underinsured population continues to add to medical liability pressures on physicians.
Proposed action: Explore expanding liability coverage under the Federal Tort Claims Act to cover physicians who treat patients in federally funded health programs, including Medicare, Medicaid, the Children's Health Insurance Program, insurance purchased with pretax dollars and nonprofit facilities. [Referred for decision to Board of Trustees]

Issue: It is unclear whether comparisons of the U.S. health care system and other developed countries are based on truly parallel data. Some countries don't include nursing home care in their health care spending estimates, and others don't count the cost of medical education. This might have resulted in skewed assessments of medical spending in the U.S.
Proposed action: Research the reported cost estimates from other developed countries to clarify what is included in them compared with tallies of U.S. medical spending. Use this information to ensure that the true costs of the nation's health care system are part of the reform discussion. [Adopted]

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