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 patients."

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 reporters.

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 the press."

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 structure.

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 patients."

Information about the AMA proposal is posted at<www.voicefortheuninsured.com>.▪