AMA Delegates Back Health Insurance Mandate


CHICAGO — Individual health insurance mandates, direct-to-consumer advertising, and store-based health clinics topped the list of issues addressed at the annual meeting of the American Medical Association's House of Delegates.

On the heels of Massachusetts' new mandate that all individuals must obtain health insurance, AMA delegates voted to support a requirement that individuals and families earning more than 500% of the federal poverty level ($49,000 for individuals and $100,000 for a family of four) obtain a minimum level of catastrophic and “evidence-based” preventive health coverage. The new policy calls for using the tax structure to achieve compliance, although language about exact tax consequences is vague.

The policy also calls for individuals and families earning less than 500% of the federal poverty level to obtain coverage once refundable tax credits and other subsidies are available.

“We've taken a bold shift here, and we want to help lead this discussion because we want to have comprehensive reform,” said Dr. Edward L. Langston, a member of the AMA Board of Trustees, during a press conference at the meeting.

The recommendation would cover only a fraction of the more than 40 million uninsured Americans. About 11% of the uninsured had incomes that were more than 500% of the federal poverty level in 2004, according to an analysis by the Department of Health and Human Services. But the delegates' action gives AMA officials another tool with which to lobby for expanding the number of people with health coverage, said AMA Board of Trustees member Dr. Ardis D. Hoven.

The new policy has the support of the American College of Physicians and the American Academy of Family Physicians; the American College of Obstetricians and Gynecologists has made no comment on the policy at this time. The endorsement of an individual mandate for coverage will bring the country one step closer to universal coverage, said Dr. Donna Sweet, an ACP delegate. Creating a market for insurance has the potential to bring down the cost of coverage, said Dr. Mary T. Herald, also an ACP delegate. “The insurance companies will love it and, hopefully, they will lower their premiums,” she said.

Dr. Daniel Heinemann, an AAFP alternate, praised the AMA policy of individual insurance responsibility as an initial step in creating health care access for all.

But Dr. David McKalip, an alternate delegate from Florida, said the AMA should stick with its current policy of using tax credits to broaden access to health insurance without imposing a requirement. Similar requirements for auto insurance, which are in place in 47 states, have failed to achieve universal insurance coverage, with noncompliance rates of 15%–30% despite penalties, he said. In addition, the Internal Revenue Service won't be able to enforce this type of policy, he said.

An individual insurance mandate would not solve the problems of free riders within the system and would result in a large bureaucracy to track compliance with the requirement, Dr. McKalip said.

Instead, Dr. McKalip proposed monitoring the effects of the individual health insurance mandate in Massachusetts. An individual mandate is a step toward socialized medicine and a “slippery slope,” he said.

In other issues, many physicians at the House of Delegates meeting expressed both dissatisfaction with the store-based health clinics that have sprung up in retail stores and pharmacies around the country and resignation that these clinics are here to stay.

In an effort to deal with that new reality, AMA delegates established principles for operating store-based health clinics, which include limiting their scope of practice, using standardized medical protocols from evidence-based guidelines, and informing patients in advance of the qualifications of those providing their care. In addition, the delegates called on the management of store-based health clinics to establish arrangements for their care providers to have direct access to and supervision by allopathic and osteopathic physicians, as consistent with state laws.

Clinic providers also should encourage patients to establish care with a primary care physician, the new AMA policy said.

Dr. Larry Fields, AAFP president, said the AMA guidelines are consistent with the principles for store-based health clinics developed by his organization and are necessary to ensure patient safety and to control the scope of these clinics.

In the area of direct-to-consumer advertising, AMA delegates voted in favor of placing a moratorium on DTC advertising for newly approved prescription drugs and medical devices until physicians have become educated about the new products. Under the AMA policy, the length of the moratorium would be determined on a product-by-product basis by the FDA in consultation with the drug or device sponsor.


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