When the AMA House of Delegates votes to approve policy, people take notice. But sometimes what this policymaking body decides not to decide is also noteworthy.

Two high-profile items on the house agenda—rescinding the AMA's support for the individual mandate to buy health insurance as part of health care reform and a resolution supporting civil marriage for same-sex couples and repeal of the Defense of Marriage Act—were the subject of lengthy and sometimes passionate debate but were ultimately "referred" for later decision.

A resolution brought to the house by delegations from Kansas, Alabama, the District of Columbia, Florida, and Georgia, as well as the American Society of General Surgeons, would have called on the AMA to "support the use of tax incentives and other noncompulsory measures, rather than a federally imposed requirement that individuals purchase health insurance."

The individual mandate—which was included in the Patient Protection and Affordable Care Act (PPACA)—is one of the more politically charged elements of the new health care reform law. And the resolution brought by the surgeons and the five states asserted that "polling throughout the past year has repeatedly shown that a solid majority of the American people oppose a federal mandate that individuals must purchase health insurance."

The resolution also noted that 21 states are challenging the constitutional authority of Congress to mandate that individuals must either purchase health insurance or pay a tax as a fine.

Supporters of the resolution testified during reference committee hearings (where all items are debated prior to the meeting of the house) that the mandate conflicts with existing AMA policy in support of pluralism and free-market economic approaches, and that there are noncompulsory measures—such as tax incentives and health savings accounts—that could effectively serve as alternatives to a federally imposed requirement.

But John McIntyre, M.D., APA senior delegate to the Section Council on Psychiatry and a member of the AMA's Council on Medical Services (which has been central in formulating AMA health care reform policy), emphasized that the individual mandate was approved by the House of Delegates as AMA policy more than four years ago, in June 2006. And he said that the mandate—which was a requirement of the private insurance industry for its support of the law passed this year by Congress—was necessary to win support for other health insurance reforms advocated by the AMA.

"The mandate is a part of the AMA's support for the principle of individual responsibility to purchase insurance," McIntyre told Psychiatric News after the meeting. "You can't have these other reforms, such as elimination of exclusions based on preexisting conditions, unless the pool of insured is large enough. And during the negotiations around the law, it was the private insurers that required it, or they wouldn't participate."

During reference committee hearings, Erick Eiting, M.D., M.P.H., assistant commissioner for government relations for the Medical Society of the State of New York, said the PPACA was far from perfect for doctors or patients, but did provide meaningful insurance reform—especially guaranteed issue and an end to discrimination based on preexisting conditions.

"Though we need these reforms to protect our patients, they also create an incentive to delay purchasing private insurance until they become sick," Eiting testified. "An individual mandate is the safeguard that prevents this from happening. It ensures that healthy people contribute to the pool so they can get the care they need when they become sick. Without a mandate, healthy people opt out of coverage, leaving a pool of only sick people. This drives up costs of insurance, creating a greater incentive for more healthy people to opt out, eventually creating a death spiral.

"My fear is that without an individual mandate, private insurance will go away. We already see this happening with BlueCross BlueShield in Oregon, where they have stopped writing policies for child-only coverage," Eiting said. "We cannot have a system that drives insurance companies to deny coverage to the sickest people who need it the most."

Even more indicative of divisions within the House of Delegates was protracted debate on a resolution written by the Medical Student Section that would have, if approved, called on the AMA to recognize that denial of civil marriage to same-sex couples contributes to health care disparities among gay and lesbian individuals and to support the repeal of the Defense of Marriage Act (DOMA).

The resolution received the vocal support of members of the Section Council on Psychiatry who noted that APA has a policy supporting civil marriage. But most striking was the virtually unanimous support for the resolution among the youngest members of the House of Delegates, who have brought to the AMA a keen interest in public health and social-justice issues.

"Same-sex couples form long-term, healthy, and satisfying relationships similar to those of heterosexual couples," said psychiatrist Paul O'Leary, M.D., a delegate from the Resident and Fellow Section. He added that there are advantages to civil marriage—emotional, physical, and economic—that accrue to parents and children of same-sex couples.

But a number of physicians said they believed support of civil marriage is a social and political issue, not a medical one, that is divisive within American society generally and within the House of Delegates.

The influence on the debate of the recent Republican sweep to victory in mid-term Congressional elections—which occurred just four days prior to the meeting of the AMA delegates—was evident in remarks made by Madelyne Butler, M.D., president of the Florida Medical Association.

She said the AMA would need Republican support for the Medicare Patient Empowerment Act, an AMA-sponsored bill allowing Medicare patients to keep their benefits when they contract privately with a physician of their choice. (Under current regulations, the only way physicians can negotiate a separate fee is by formally "opting out" of Medicare, which removes the physician from Medicare for two years and necessitates each patient's signing a statement acknowledging that he or she cannot be reimbursed by Medicare for services provided by that physician. The AMA-sponsored bill would allow physicians and patients to contract privately with each other for a fee different from the Medicare fee, while still allowing patients to use Medicare benefits for partial reimbursement. With little or no debate at all, delegates at the San Diego meeting approved a resolution calling on the AMA to "commit to a well-funded and top-priority legislative and grassroots campaign" to ensure passage of the bill.)

But Butler said support for civil marriage and repeal of DOMA by the House of Delegates would dominate headlines and jeopardize Congressional support for the private-contracting bill.

"This will be a headline item if we pass this resolution," she told delegates during reference committee hearings on the civil-marriage resolution. "It will alienate our patients, and it will alienate the new Republican majority that has taken over the House [of Representatives]. I would not want it put forth that this is the major issue facing medicine today or trumpeted in the newspapers that this is the only thing we have done at this meeting."