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After vigorous debate, the American Medical Association (AMA) House of Delegates took a major step Monday toward allowing the organization to advocate for a public option to ensure that more low-income people have health coverage.

During its interim meeting held virtually and in Honolulu, members approved a resolution that calls for the organization to "advocate for a pluralistic healthcare system, which may include a public option, that focuses on increasing equity and access, is cost conscious, and reduces burden on physicians."

However, several members noted that the resolution could be interpreted as a call for the AMA to advocate for a government-run single-payer system, which members have long opposed. They expressed fears that if the government ran a single-payer system, physicians would not be paid anywhere near their costs.

But Ryan Mire, MD, president of the American College of Physicians, repeatedly insisted that "the public option is not single payer. It is just an option for those who do not have insurance, and those who fall within the gaps of coverage."

Physician proponents had previously noted that many Americans lost health coverage when they lost their jobs during the COVID-19 pandemic, and the Affordable Care Act (ACA) marketplaces or exchanges often have high premiums, high deductibles, and cost sharing that is out of reach for many people.

Corey Howard, MD, of the Florida Medical Association, said that while the resolution appears benign, "it implies the AMA would advocate for a public option," adding that when pluralistic health system reforms have been discussed by the AMA in past years, the overriding theme is that "we'll look at everything," but "with strong opposition to a single-payer system."

"AMA policy is that the creation of a new single-payer system, government-run healthcare system, is not in the best interest of the country and must not be part of the national healthcare reform," he said, pointing out the "detrimental" nature of unfair concentration of market powers and payers.

Several speakers also expressed concerns that a single-payer system would follow a pricing model guided by Medicare payment rates, which have been historically much lower than what commercial plans pay, arguing that in the absence of other sources of payment, physician practices would have to close.

Eli Freiman, MD, of the Massachusetts delegation, tried to refute this argument. "Our patients are suffering, and access to healthcare in this country is woefully inadequate," he said. "We have millions of uninsured patients and the [ACA] exchanges are not enough. It is our charge as physicians to make it better."

"Nobody wants a public option that pays at a rate that isn't sustainable for physicians and practices," he added, noting that the resolution specifically states that any "physician payments under the public option are established through meaningful negotiations and contracts" and "must be higher than prevailing Medicare rates and at rates sufficient to sustain the costs of medical practice."

According to Sarah Marsicek, MD, a delegate from the American Academy of Pediatrics, it's important for the AMA to move now.

"Looking ahead to 2023, we are expecting a massive disruption to insurance coverage when the Medicaid continuous coverage requirement implanted during the pandemic comes to an end," she said. "More than 15 million people are expected to lose their coverage, including more than 5 million children and hundreds of thousands of people will be left with no affordable coverage in states that have not expanded Medicaid."

Down With Due Process Waivers

Healthcare workers should not be required to sign contracts waiving due process as a condition of their employment, as many are increasingly being required to do, and AMA policy going forward authorizes the organization to work to discourage such requirements, approving a resolution that said, in part, "It is in the interest of society for healthcare workers to be able to freely raise patient and healthcare worker safety concerns."

In a prolonged and lively debate, several speakers suggested that the issue is very complicated, especially for small practices that need such clauses to quickly sever their relationships with disloyal or disruptive physicians, and that the AMA needs to take more time to study the issue.

Lynn Parry, MD, of the Colorado delegation who spoke on behalf of herself, said that while due process is important to prevent "institutional large practice abuses," waivers are useful for the rapidly declining number of smaller independent physician groups. "Small practices cannot afford to have a toxic person who can destroy the practice ... There's another population of physicians who also need to be protected."

Frank Dowling, MD, a delegate from New York who also spoke for himself, noted that he cares for many other physicians referred by physician health programs, medical staffs, or department chiefs for assessment of substance abuse or mental health issues. "And very often I have to sift through to figure out, is there really a problem or is this political?"

Sometimes, a doctor may have behaved "less than their best on a given day, and discipline may not have been unreasonable," he explained. But, "it is a common tactic that I see over and over every year with new referrals for assessment that a doctor is coerced into signing an agreement that gives them, 'no harm, no foul' for now. But if anything else negative happens, you can be expected to voluntarily resign. All due process is lost."

Gary Gaddis, MD, PhD, of the Academic Physicians Section, strongly urged approval to give doctors a stronger tool to protect other employees within health systems, noting that due process "lets us protect the nurses with whom we work or the patients we serve [against] misguided or wrongheaded policies coming from the C-suite."

Speaking for herself, Anna Yap, MD, of the American Association of Public Health Physicians, said she's among many residents who will eventually look for a permanent job. "We are having to look at employment contracts that aren't allowing us to have due process. This is a workforce wellness issue," she noted, adding that young physicians need ways to protect themselves and still get good jobs, "but that is difficult, especially in states that do not give us those protections."

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