The AMA's policymaking body, the House of Delegates (house), includes representatives of state medical societies and specialty and subspecialty organizations, with representation proportional to the number of AMA members. Other groups such as medical students, residents, “young physicians,” the military, medical schools, and “organized medical staff” also have a vote. While historically the AMA functioned as a confederation of state organizations, over the past decade, there has been an increasing presence and visibility of specialties in the house. Although for much of its history, the AMA required dual membership (nationally and in state societies), physicians may join the AMA without being members of their state medical societies, and vice versa. This “unbundling” of membership several decades ago turned out to be costly to both groups, with losses outstripping gains in membership.