House Reform Bill Wins AMA Support, Though Process Often Contentious

The AMA House of Delegates backed its Board of Trustees last month when it voted to affirm the board's support of the Affordable Health Care for America Act (HR 3962).

After a total of nearly 11 hours of debate, including a daylong marathon in reference committee hearings where AMA proposals were discussed before moving to the full house for consideration, delegates approved a 14-item resolution expressing support for the board's decision and outlining what delegates want—and do not want—in health care reform.

It was a momentous AMA meeting—the phrase “defining moment” got a vigorous workout—with the House of Representatives' passage of HR 3962, the trillion-dollar health care reform bill, late on the evening of Friday, November 7, just a day before the AMA House of Delegates convened.

The week before the congressional vote, the AMA's board decided to support the bill. That infuriated some members of the AMA House of Delegates, who arrived at the Interim Meeting in Houston determined to overturn the decision. Among them was a Florida physician who called HR 3962 a “massive intrusion of the government into the practice of medicine.”

Most of those opposed to the board's decision also cited the bills' support for the so-called “public option” and the absence of significant medical liability reform.

So at issue during the AMA debate were not only the myriad details of health care reform, but the question of whether the House of Delegates—which sets policy for the organization—trusts the board to act in the organization's best interests during the quickly changing, helter-skelter process by which legislation gets made in Washington.

(Following the AMA board's decision to support HR 3962, the executive committee of the APA Board of Trustees did so as well. In late summer, the AMA and APA boards had endorsed HR 3200, an earlier, similar version of the bill.)

One last-minute resolution introduced at the AMA meeting explicitly called for the house to rescind the board's decision. It was supported by 13 state societies and six surgical specialty organizations. But opponents of the AMA board decision were easily outnumbered by supporters, who included primary care physicians and most other specialty organizations, including the Section Council on Psychiatry.

During reference committee hearings, John McIntyre, M.D., chair of the Section Council on Psychiatry, urged delegates to support the board and said support of HR 3962 enabled the AMA to remain in the game as the scene moves to the Senate and later presumably to a conference committee bill.

“It would have been easy for [the board] to kick the can down the road a bit,” he said. “But we needed to support the bill to stay at the table. The real challenge now is not to look back, but to look forward.”

In an interview with Psychiatric News, McIntyre noted that HR 3962 is considerably better than an earlier House version (HR 3200, the America's Affordable Health Choices Act) in part because of the presence of the AMA at the negotiating table. And though the current bill is far from perfect, he said HR 3962 offers several things that the AMA has advocated for years, such as insurance market reform and reform of the administrative claims process.

He emphasized that the AMA board supported 3962 without endorsing it—a distinction that may lack a difference outside of the nation's capital, but in policymaking circles is an important one. “‘Endorse’ means you think it's perfect and love it the way it is,” McIntyre explained. “‘Support’ means there is enough there to keep it moving while realizing there are things that need to be changed.

“The question for the board [with 3962] was how much of a role the AMA would play in shaping the final product,” he said. “Their decision was that this was the only bill and the only chance to keep reform going.”

McIntyre added that he believes the process should serve as an illustration of the essential role that the AMA has played in helping to shape health care reform. “How can anyone look at what has happened and still think the AMA is irrelevant?”

Medicare Commission Opposed

What the House of Delegates ultimately approved was an extensive resolution that expressed its support for the board and its commitment to working for health care reform consistent with critical elements of AMA policy (see Original article: Delegates Outline Objections to Current Reform Proposals).

On top of the lengthy debate about supporting the board's decision was intensive wordsmithing of 14 resolutions addressing the content of health care reform.

Several of these elicited their own mini-marathon of argument—especially regarding possible redistribution of Medicare payments from specialty care to primary care and the potential creation of an independent commission to govern Medicare payment.

Delegates approved an item stating that the AMA “actively and publicly opposes the Independent Medicare Commission (or other similar construct), which would take Medicare payment policy out of the hands of Congress.”

Mario Motta, M.D., an internist from Massachusetts, likened such a commission to the base-closing panels established in the 1990s to shutter military bases. “It's important that [physician payment] stay in Congress and not be placed in the hands of an unelected commission,” he said. “Congress wants to wash its hands of the problem of physician payment.”

Another of the 14 items was devoted to objectionable prospects for health care reform that are currently under consideration by the Senate.

AMA Action Could Affect Membership

Throughout the debate, opponents of the board's decision to support HR 3962 testified about physician colleagues at home who either resigned their AMA membership or were threatening to do so because of the board's decision.

In contrast, supporters cited the AMA's reputation over the years as a nay-sayer—voting against Medicare in 1965 and the Clinton health care reform proposal in the 1990s, as well as the organization's opposition to the National Practitioner Data Bank and other initiatives—and said that the AMA could gain public trust only by its support of legislation widening access to health insurance for millions of Americans.

Psychiatry section council member Patrice Harris, M.D., who is also vice chair of the AMA's Council on Legislation and was a participant in the flurry of conference calls that preceded the board's support of HR 3962, told delegates that the board's decision might reap at least as many members as it loses. “I have heard from doctors in Atlanta who are thinking of joining or rejoining the AMA because of its recent decision,” she said.

Addiction psychiatrist Michael Miller, M.D., seemed to sum up the majority position when he spoke at the end of nearly eight hours of reference committee debate. “I think our board has been extraordinarily courageous under very difficult circumstances in a political process, understanding that we want tort reform, and we aren't going to get it, and that we want things to happen but that politics is the art of the possible,” he said.

“Do we think there is any chance the AMA would have gotten anything we wanted if we had not been at the table?” Miller asked. “To repudiate [the board's decision] now would be a vote of no-confidence in the board. We had to support [HR 3962] to keep the process going. To reverse that says we want the process to stop. I don't want it to stop, and I don't think the American people want it to stop.”

The resolution on health care reform approved by the AMA House of Delegates is posted at <www.ama-assn.org/assets/meeting/mm/i-09-ref-comm-b-annotated.pdf>.