With health system reform looming as a central issue in the 2008
presidential race, members of the AMA House of Delegates focused on strategies
to advance the AMA's own proposals.
Medicare reform, state health care reform initiatives, the AMA's
longstanding opposition to a "single-payer" system of health care,
and pending legislation to reauthorize the State Children's Health Insurance
Program dominated debate at last month's interim meeting of the AMA House of
Delegates in Honolulu (see also Physicians Face Drastic Cut in 2008 Medicare
Indicative of the urgency felt by delegates surrounding health care reform
efforts was a resolution that would have had the AMA sponsor a forum on health
care reform for all the major presidential candidates at the AMA's annual
meeting in June 2008.
Ultimately referred to the AMA board, the resolution was nevertheless
strongly supported by some delegates who felt that the time was ripe to
confront presidential hopefuls and to assert the AMA's proposal for reform.
That proposal emphasizes use of tax credits and deductions to promote private
ownership of health insurance and free-market choice.
"This is where the tire meets the road," said Arthur Palamara,
M.D., a delegate from Hollywood, Fla. "We have a group of people in the
running for president who all have proposals for health care reform. We should
have the opportunity to interact with those individuals, and we believe the
AMA is the perfect forum for this, as well as a tremendous opportunity to
exert influence over the process."
But many other delegates argued successfully that the logistical
difficulties of sponsoring such an event, especially with regard to security
requirements, would be overwhelming, and the resolution was sent to the board
Nevertheless, the discussion about a presidential forum reflected an
atmosphere of anticipation and anxiety about a deteriorating health care
system and the need for urgent change. Among the most passionately debated
issues at the meeting was one that has been an article of faith for AMA policy
since the 1980s—opposition to the prohibition on balance billing under
the Medicare program.
The house resolved to "devote the necessary political and financial
resources to introduce national legislation at the appropriate time to bring
about implementation of Medicare balance billing and to introduce legislation
to end the budget-neutral restrictions inherent in the current Medicare
physician payment structure that interferes with patient access to
According to the resolution approved by delegates, this legislation should
be designed to preempt state laws that prohibit balance billing and prohibit
the inappropriate inclusion of balance-billing bans in physicians' insurance
contracts. The AMA also will develop model language for physicians to
incorporate into insurance contracts that attempt to restrict a physician's
right to balance bill any insured
Jeremy Lazarus, M.D. (left), is believed to be the first psychiatrist to
serve as speaker of the AMA House of Delegates. As speaker, he presides over
proceedings of the house and serves on the AMA Board of Trustees. At right is
the vice speaker, Andrew Gurman, M.D.
Credit: Mark Moran
The renewed urgency around the issue of balance billing came amid
increasing frustration with efforts to reform the Medicare payment
formula—especially the so-called "sustainable growth rate"
(SGR) component that requires the program to remain budget neutral—and a
sense that the only way to force change in the Medicare payment scheme was to
enlist the voice of patients.
Characteristic of the careful parsing of words that sometimes takes place
on the house floor, considerable energy was spent discussing a change to the
resolution that would have advocated "immediate" implementation of
balance billing, as opposed to implementation "at the appropriate
Past AMA President Donald Palmisano, M.D., argued for"
immediate" action saying, "The ship is sinking."
Peter Levine, M.D., a delegate from the District of Columbia, said efforts
to reform the payment formula otherwise were fated to failure. "It is a
fantasy to think that Congress will do anything to fix the SGR," Levine
said on the house floor. "If we wait until the SGR is fixed, we will be
waiting forever. We should demand balance billing, and do it now."
But other delegates argued successfully that AMA lobbyists need the
latitude to determine a politically appropriate time to introduce legislation
and noted that balance billing is a volatile topic for elderly patients and
for advocacy organizations such as AARP.
"The timing of legislation is critical," said Sheldon Gross, a
delegate from Texas. "In the eyes of AARP, for us to demand balance
billing immediately is the equivalent of holy war."
Attention was drawn on the house floor to the fact that AARP President
William Novelli had issued a statement, in time for the AMA meeting, urging
reform of the Medicare payment formula. The statement was distributed to house
"The problem has intensified in recent years and is destined to
become even worse," Novelli wrote. "If Congress doesn't act by the
end of 2007, doctors will face an unprecedented 10 percent cut in Medicare
payments next year. Should that occur, 60 percent of physicians say they'll be
forced to limit the number of new Medicare patients they accept...."
Reflecting ongoing controversy at the congressional level over eligibility
limits for the State Children's Health Insurance Program, delegates also held
a heated debate about a proposal that would have capped the program
eligibility at 200 percent of the federal poverty level (see AMA Debates
Coverage in SCHIP Legislation).
The house also approved a report by the AMA's Council on Medical Services
(CMS) offering guidelines for state health system reform proposals. That
report emphasized that "health insurance coverage for state residents
should be universal, continuous, and portable."
The original report did not include the specific mention of mental health
benefits and avoided making recommendations regarding what would constitute a
meaningful benefits package.
The house, however, amended the report to recommend that the health care
system should "emphasize patient choice of plans and health benefits,
including mental health, which should be value-based."
Another amendment recommends that coverage be made mandatory only if health
insurance subsidies are available for those living below "a defined
In testimony during reference committee hearings prior to the meeting of
the house, CMS member Barbara McAneny, M.D., of Albuquerque, N.M., stated that
the council opted for "value-based" purchasing of individual
health plans, with a variety of options that might include coverage of mental
health benefits, over unwieldy efforts to craft a mandated essential benefits
She emphasized that the AMA already had extensive policy on its books in
support of mental health parity.
But psychiatry section council member Jeffrey Akaka, M.D., argued that
allowing the market to determine the availability of mental health benefits
would almost certainly ensure the absence of those benefits. "The market
for behavioral health is not a good market," he said. "Mental
health is essential to any meaningful benefit plan."
John McIntyre, M.D., chair of the Section Council on Psychiatry and a CMS
member, said the recommendation to include the language about mental health in
the report was deemed acceptable to council members, and it was approved by
the full House of Delegates without debate. But he echoed McAneny in saying
that CMS had early on determined that trying to write a "laundry
list" of services to be covered in an ideal system would be all but
"So we were happy to include the language about mental health but
decided we would resist efforts to start adding other things to the laundry
list. If you try to define a specific benefit package, the discussion then
becomes about what is essential and what is not. [CMS] decided that what made
sense was to focus on patient choice and value-based purchasing of insurance
Another indication of the concern within the AMA ranks about the direction
reform efforts may take was an extended debate during reference committee
hearings and on the house floor about a resolution to spend $10 million on an
advertising campaign against a single-payer system of health care
The AMA has for decades been among the staunchest opponents of a
Canadian-style single-payer system under which health care is financed by the
government. But some of the testimony on the floor of the house reflected a
possible softening of that opposition, especially among younger members, and a
realization that there are a substantial number of American doctors who favor
a single-payer system.
Palmisano argued on the floor of the house for an advertising campaign,
saying that an aggressive approach to opposing a single-payer system would
attract new members to the organization. "We should not be afraid"
to take that position, Palmisano said.
But the motion was defeated by delegates who did not want the AMA's name
associated with negative campaigning. "Regardless of whether we are
opposed to single payer, we need to be positive in the way we word things as
we approach the entire populace of America," said Benjamin Whitten,
M.D., an alternate delegate from Wisconsin. "We should be expressing the
will of doctors in terms of positives. Let's not make the headlines a
negative. Let's be for things, not against something."
Ruth Cobell, M.D., from the Section on Medical Schools, said there are
physicians in America who support a single-payer system. "We can drive
membership down, not up, by taking a negative approach," she said.
Information on the AMA proposal for health care reform is posted at<www.voicefortheuninsured.com>.▪