The much-talked about "public option" for health insurance is a
bit like a Rorschach inkblot test—what one person sees in it may not be
what the next person sees.
President Obama has favored inclusion of a publicly funded health insurance
option in health system reform, a preference he repeated in his speech last
month to the AMA's House of Delegates during the AMA's annual policymaking
meeting (see Obama Seeks M.D.'s Help to Reform Health Care). But the exact
shape of that public option and how it will function alongside a private
insurance market remain to be determined.
It was in the face of such uncertainty—and with the awareness that
legislators and the media were looking to the AMA for a response to the
president—that delegates labored during the meeting to craft the
following resolution regarding a public option: that the AMA "support
health system reform alternatives that are consistent with AMA principles of
pluralism, freedom of choice, freedom of practice, and universal access for
The statement was the result of hours of debate in reference committee
hearings and on the floor of the House of Delegates, and the
intervention—twice—by AMA immediate past President Nancy Nielsen,
M.D., during debate on the house floor to ask for last-minute word changes.
(Nielsen and other AMA leaders have been involved in discussions with Obama
and congressional leaders about health system reform.)
It was also the product of a House of Delegates that is deeply ambivalent
about a public option, the shape of which is still unknown. In one
camp are delegates who are skeptical about more government involvement in
American health care and who see in the public option a "stealth
single-payer plan" that will eventually eliminate private insurance. In
another camp are those who see in the public option an important means for
insuring individuals who cannot afford private insurance and who say the
private insurance market has been no friend to doctors or patients.
Additionally there was the awareness that the AMA could not afford to
appear unwilling to negotiate about any proposal for reforming what is now
universally agreed to be a broken system.
"We are open to all possibilities, and we will evaluate them,"
Nielsen told reporters after the debate. "The delegates could have sent
a closed-door message, but they didn't."
But Nielsen did say the AMA was clearly opposed to a single-payer plan and
to expansion of the Medicare program, which she said was "already
insolvent." She added that the AMA wants to maintain private contracting
and opposes any form of physician or patient mandate.
"Mandates are offensive to the American spirit," Nielsen told
The resolution finally approved was essentially a statement for the press,
public, and lawmakers—not a statement of new policy. John McIntyre,
M.D., chair of the Section Council on Psychiatry, pointed out that the AMA
already has an elaborately detailed policy proposal for universal coverage and
access to health care that focuses on tax credits to expand purchasing power
by individuals and regulatory changes to the existing insurance market, such
as eliminating preexisting-illness exclusions.
McIntyre said that a majority of delegates—and the Council on Medical
Services on which he serves and which has jurisdiction over issues related to
reform—were in favor of considering a public option, but the
apprehension among some that even the term "public option" might
be construed to mean a single-payer plan led the house to jettison the phrase
from its final statement.
"There are a large number of physicians in the house who clearly
favor a public option if it meets certain criteria," McIntyre told
Psychiatric News. "But the term means different things to
different people, and in many circles it has become a buzzword for a negative.
The concern was about what it would mean to AMA members who were not present
at the meeting and how it might be taken out of context and misconstrued by
Despite the length of the debate around a public option, there was a
remarkable amount of agreement on some points, such that one physician
commented during reference committee hearings that delegates seemed to be in"
vehement agreement" with each other: a public option should not
replace the private market system, should not coerce physicians or patients,
should not morph into a single-payer plan, and should not duplicate the
Medicare program with its flawed payment system and insolvent financial
Still, some delegates were insistent that the AMA should "draw a
line" beyond which it would refuse to go. The Kansas delegation
sponsored a resolution opposing the public option, and Richard Warner, M.D., a
delegation member, predicted the public plan would draw more than a hundred
million people away from private insurance plans when large employers opted
for it, thus killing competition.
"The time has come to be totally unashamed to say that there is
something we do oppose," he said. "It is simply being very clear
that the AMA [does not support] a plan that is an extension of Medicare or one
that looks like Medicare in which the insurance company is both a player and a
referee of the competition. I think we should be very clear, identify the most
unacceptable possibility, and say 'Absolutely we oppose that. Don't waste your
time with that.'"
Countering that was Lori Heim, M.D., of the American Academy of Family
Physicians, who stated that the public option need not be a replica of
Medicare and could be an important tool for promoting competition. "This
is a way to keep insurance companies honest," she said. "Right now
they are not always playing fairly with us. This is a way of enhancing
competition and increasing coverage."
Mario Motta, M.D., president of the Massachusetts Medical Society, echoed
that and pointed to successful public-private systems in France, Switzerland,
Belgium, and Australia. "Having an insurance option that is publicly
supported would tell the [private health insurance companies] of the world,
'You are not going to be able to pay your CEO $50 million bonuses this year,
and you are not going to be able to keep the 30 percent overhead," he
said. "I don't see anything wrong with that."
Speaking for the AMA Board of Trustees, and reflecting what appeared to be
the view of the majority of physicians in the house, board member Samantha
Rossman, M.D., said that the AMA could not afford to absent itself from
negotiations by opposing the public option from the start.
"The phrase 'public plan' has become so muddied as to be useless
except as political fodder," she said. "There are a lot of options
being tossed around—that is why we need to be at the table. We are
absolutely committed to advocating for a system that works for doctors and
Information about the AMA proposal is posted at<www.voicefortheuninsured.com>.▪