AMA House of Delegates

Massachusetts oncologist Jack Evjy, MD, was among those speaking in support of an individual requirement to obtain health insurance. The issue drew emotional debate from a multitude of physicians. Photo by Peter Wynn Thompson

AMA delegates reaffirm key reform policy but target parts of law for change

■ The AMA house directed the Association to seek repeal of the Medicare Independent Payment Advisory Board and a provision expanding nonphysicians' scope of practice.

By Emily Berry , Kevin B. O’Reilly — Posted July 4, 2011

Chicago -- AMA delegates reaffirmed policy calling for "individual responsibility" to obtain health insurance. They rejected a bid to have the AMA oppose the individual mandate provision of the health system reform law.

The House of Delegates' vote by a 2-1 ratio approved a report from the Council on Medical Service that called for keeping existing policies.

The first policy states that "our AMA is committed to achieving the enactment of health system reforms that include health insurance coverage for all Americans, and insurance market reforms that expand choice of affordable coverage and are consistent with AMA policies concerning pluralism, freedom of choice, freedom of practice and universal access for patients."

The policy that supports individual responsibility was adopted in 2006. It specifies that families with an income greater than 500% of the federal poverty level should be required to buy insurance that includes preventive and catastrophic coverage.

The policy supports "using the tax structure to achieve compliance." It says those with lower incomes should not be subject to such a requirement unless they are granted tax credits or other subsidies to help offset the cost of coverage.

A second policy reaffirmed in the report advocates that "state governments be given the freedom to develop and test different models for covering the uninsured."

Delegates rejected by 59% to 41% a proposed amendment that offered stronger support for states' prerogative to set their own policies, including their right to opt out of the federal mandate. "I believe that each state, working with the population it has and specific problems it has, can craft a solution that works better for that state perhaps than the one next door," Michael Greene, MD, a family physician and delegate of the Medical Assn. of Georgia from Macon, said in support of the proposed amendment. "There are other ways to get to the same end point."

AMA policy and the reform law

Dalton, Ga., family physician John S. Antalis, MD, said the health system reform law hurts businesses. "The bottom line is ... they are being chased by government regulation. They cannot invest. They do not feel comfortable because of too many government regulations that are inhibiting their ability to help stimulate the economy." Photo by Peter Wynn Thompson

AMA policy calls for "individual responsibility" and does not include the word "mandate." But debate among delegates often focused on the risks and benefits of the AMA being seen as supporting the coverage requirement that is part of the Patient Protection and Affordable Care Act. During reference committee testimony and discussion on the house floor, advocates for a requirement to buy health insurance sparred with those who believed that individual freedom from government requirements was paramount, above even expanding insurance coverage.

Massachusetts' state-level mandate, which took effect in 2006, became a touchstone for both supporters and opponents of a requirement to obtain coverage. Each side claimed the state's experience supported its position.

Jack Evjy, MD, an oncologist and former president of the Massachusetts Medical Society, was one of several doctors defending Massachusetts' mandate. He testified on Father's Day about his daughter, who recently died of breast cancer.

He spoke as a passionate advocate of "universal responsibility" to get coverage, citing difficulties that uninsured cancer patients have paying for costly treatments. "Everybody's got to pony up," said Dr. Evjy, a cancer survivor. "We don't do our patients any service by creating political and emotional incentives for them not to get coverage."

The requirement to buy health insurance takes effect in 2014, but legal challenges mean the issue ultimately is expected to be decided by the U.S. Supreme Court.

After the house vote approving the council's report, Cecil B. Wilson, MD, then AMA president and an internist from Winter Park, Fla., drew a distinction between the health reform law and AMA policy. "The reality is that AMA policy was set long before the [Affordable Care Act] was even a gleam in someone's eye," he said. "Two thirds of the members of this house today said our policy is good, our policy is essential, retaining the individual responsibility for those who can afford to buy insurance. Retaining that is essential to being able to provide the expansion of coverage we hope will eventually be able to provide insurance coverage for everyone in this country."

Looking ahead on reform

Though debate about the individual mandate often was emotional, delegates' discussion on how to shape the direction of national health system policy featured much more harmony than discord.

The house adopted a resolution directing the AMA to "vigorously work" to change the law so it is in line with the Association's policies on health system reform. Delegates said the Association should seek repeal of the Medicare cost-cutting Independent Payment Advisory Board as well as a health plan-related provision that could expand nonphysicians' scope of practice.

The provision says health insurers must allow any "health care provider who is acting within the scope of that provider's license or certification under applicable state law" to participate in their plans.

AMA President Peter W. Carmel, MD, criticized the so-called nondiscrimination measure. "This provision is poorly worded, highly confusing and has the potential to expand roles and responsibilities within the health care team beyond what is appropriate based on education and training," he said.

Delegates also asked for a study on the value-based physician payment modifier. The modifier, which would change compensation based on an index of doctors' costs and quality outcomes, is scheduled for implementation in 2015 under the health reform law.

"Despite previous disagreement over the Affordable Care Act, our focus should be on fixing the defects," said Charles Rothberg, MD, an ophthalmologist from Patchogue, N.Y., and a delegate for the Medical Society of the State of New York, which introduced the resolution.

Voicing strong support for amending the health system reform law would help clarify the AMA's stance on the matter, said Bruce A. Scott, MD, an otolaryngologist and a delegate for the Kentucky Medical Assn. from Louisville who spoke on his own behalf in support of the resolution. "This will begin to satisfy some of the unhappy physicians back home who believe mistakenly that the AMA wholeheartedly backed the PPACA legislation," he said.

Delegates also called for measures such as a long-term Medicare physician payment solution, permission for full private contracting with Medicare patients, comprehensive medical liability reform, expansion of health savings accounts, and antitrust changes that would allow physicians to collectively negotiate with health insurers.

In a separate action aimed at the future of health reform, the house adopted policy supporting a requirement that all federal health care regulatory agencies use evidence-based standards of care to demonstrate "measurable improved patient outcomes" within three years of implementing a rule. Any regulation that does not meet the test should be revised or rescinded, the AMA said.

ADDITIONAL INFORMATION

Meeting notes: Legislation

Issue: Racial and ethnic disparities continue to be a major problem, but insurance status, particularly whether a patient is enrolled in Medicaid or is uninsured, also is linked to disparities.

Proposed action: Affirm the AMA's support for elimination of health care disparities based on insurance status; ask the member organizations of the Commission to End Health Care Disparities to address insurance status specifically; and urge the Agency for Healthcare Research and Quality to investigate the impact of insurance-based segregation in different settings on racial and ethnic health care disparities. [Adopted]

Issue: The federal government is working to define what it will call essential health care benefits that must be covered by plans for sale in the state-based health insurance exchanges.

Proposed action: Rather than recommend a list of specific benefits, reaffirm existing policy stating that the coverage offered by the Federal Employee Health Benefits Program should be used as a "reference" when identifying whether a plan offers meaningful coverage for adults. [Adopted]

Issue: Accountable care organizations and other payment models that rely on assigning a population of patients to a physician increasingly are becoming more common, under both Medicare and private payers.

Proposed action: Advocate for Medicare payment reforms that "emphasize voluntary agreements between patients and physicians, minimize the use of algorithms or formulas, provide attribution information to physicians in a timely manner, and include formal mechanisms to allow physicians to verify and correct attribution data as necessary." [Adopted]

Issue: Laws that bar gays and lesbians from marrying not only limit their access to insurance and other health benefits but also can impose psychological harm.

Proposed action: Modify existing policy to recognize that denying civil marriage based on sexual orientation is discriminatory and stigmatizes gay and lesbian individuals, couples and their families. [Adopted]

Issue: Pharmacists are seeking to expand their scope of practice in ways that constitute the unsupervised practice of medicine, such as interpreting diagnostic tests and substantially changing patients' medication regimens.

Proposed action: Collect and disseminate state-specific information on pharmacists' scope of practice and disseminate model state legislation on the matter. [Adopted]

Issue: It is difficult for Medicare patients to determine when they are eligible to obtain certain covered preventive services.

Proposed action: Encourage the Centers for Medicare & Medicaid Services to set up a user-friendly way for patients to call in or use the Web to find out the timing of covered benefits. [Adopted]

Issue: Patient navigators often are employed by health systems or health insurers to help patients with treatment options and the intricacies of insurance coverage. There are no clear standards or accreditation requirements in this field, and patient navigators may be instructed to direct patients only to certain physicians and hospitals for care, restricting freedom of choice.

Proposed action: A report on the emerging role of patient navigators. [Adopted]

Issue: Some physicians refuse to take on-call coverage in the emergency department due to medical liability costs, worsening patients' access to quality specialist care.

Proposed action: Support federal legislation to grant physicians legal immunity under the Federal Tort Claims Act when providing care in accordance with the Emergency Medical Treatment and Active Labor Act. [Referred for decision]