The just concluded American Medical Association annual meeting displayed deeply held conflicting opinions among the voting members of its House of Delegates.
The prevailing majority endorsed individual responsibility to either purchase health insurance or pay a penalty for not participating as a fundamental aspect of health reform. This group, predominantly composed of representatives of national specialty societies, New England, Midwestern, and Western states, believes that without universal commitment to the risk pool, the ability to sustain a healthy insurance market would be uncertain. The elimination of pre-existing conditions makes “free riders” who buy insurance only at the onset of illness a potential threat by causing escalation of premiums on the remaining chronically ill, a subsequent collapse of the private market and the inevitable creation of a governmental payer system based on tax revenues.
A passionate minority of nearly 40% hold strong libertarian views and hail predominantly from Southern and mid-Southern states and small, private practice clinical sites. To them, the government should never violate individual liberty by mandating participation in an insurance pool. They generally believe that fee schedules are a violation of their autonomy, and that doctors and patients should be able to freely contract with each other to establish total fees for health services. Government regulation regarding public health issues, access to health care and the provision of medical services should be minimal. Testimony from this group is often impassioned and persistent.
The nature of the debate at the meeting left little middle ground for a mutually satisfying compromise. Moreover, it is not easy to ascertain the views of the nearly 1 million practicing physicians who are increasingly engaged in salaried practice and who have not been joining the AMA. Testimony at the House of Delegates meeting now features debates between traditional representatives (state society, private practice physicians) and a somewhat more diverse population of delegates from national specialty societies. While the AMA’s policy on health reform was essentially reaffirmed last week, the inherent tensions between these two large factions within the organization will persist for quite some time into the future.