Doctors have a Wish List for Congress

What's in the American Medical Association wish list to the federal government?

The American Medical Association (AMA) is one of the country’s largest healthcare lobbying organizations, and it has been hard at work with its “Recovery Plan for America’s Physicians.”

These policy positions have the potential to shape the future of the healthcare industry, because it includes policy on areas from telehealth and pre-authorization to Medicare. Let’s dive into what exactly the AMA is and what is so special about its recovery plan.

Some Background

The AMA came about in the mid 19th-century amid pushes to standardize education for medical professionals and efforts to address ethical concerns. Through the rest of the century, the organization expanded its programs to advance scientific discovery and application of medicine, improve safety for patients, and overall improve public health. The organization created the notable peer-reviewed Journal of the American Medical Association (JAMA) which publishes research on specialty medicine.

In the early 1900s, the AMA helped facilitate the creation of standards for educating medical professionals. It supported the landmark Flexner Report. In surveying the state of medical education across the country, the report called for a significant reduction in the number of medical schools, restriction of state medical licenses, and higher prerequisites to start medical training. These recommendations drove up the cost of healthcare services due to more stringent education, but quality of care arguably improved as well.

However, the report has notably been criticized for racism because it focused on the treatment of black Americans to protect the health of white Americans they were in contact with, not for the sake of black Americans’ own health. The report also recommended the closure of most black medical schools and in the long-run reinforced segregation.

The AMA ramped up its position as a powerful lobbying force within the US government. In the 1890’s, the AMA promoted passage of laws to make smallpox vaccinations mandatory, and in the 1920’s, the AMA proved instrumental in the passage of the Caustic Poison Act which required product label warnings if an item contained certain caustic chemicals.

The organization in the 70’s was similarly activist — launching a “war on smoking”, making public calls for handicap access to buildings, urged a focus on treating hypertension, and speaking out against gender and sexual orientation discrimination.

Fights Over Health Coverage Laws

In the early 20th century, the AMA also held a strong position against compulsory health insurance at state and federal levels. These compulsory health insurance programs would likely reduce the cost of health coverage for patients, but it took away from the physician’s power to set their own prices.

President Truman, in 1945, laid out a strategy to support the development of the American healthcare system. It aimed to invest in public health services, research, and training for medical professionals. Most notably, this was also the first proposal for a national health insurance plan that Americans would pay for through payroll taxes. He stressed that patients and physicians would retain freedom to choose health services and that the intent was to ensure any patient can receive care.

The AMA railed against the plan — capitalizing on paranoia about the USSR by decrying the plan as “socialist”. In a change of policy stance preferring that there be no third-party in the patient-provider relationship, the AMA proposed increasing the usage of private health insurance plans. Truman was quite upset at this:

Socialism is a scare word they have hurled at every advance the people have made in the last 20 years. Socialism is what they called public power. Socialism is what they called social security. Socialism is what they called farm price supports. Socialism is what they called bank deposit insurance. Socialism is what they called the growth of free and independent labor organizations. Socialism is their name for almost anything that helps all the people.

President Harry S. Truman

By the time Truman and his party lost control of Congress, the bill died, and it was what he considered one of his most troublesome moments as president.

When the Medicare bill was making its way through Congress in the mid-1960’s, the AMA pursued Operation Coffee Cup to get physicians and their spouses to rally support against Medicare (one notable supporter of their case was a younger Ronald Reagan). It must be noted that since the passage of Medicare, the AMA has opposed cuts to the program.

Since then, the AMA has made efforts to curb the cost of liability insurance for physicians and at the end of the 2000’s called for expanding access to healthcare coverage. During the passage of the Affordable Care Act (ACA), the AMA provided its “qualified support” to the Obama administration in passing it.

What’s interesting to note is that the AMA does not represent all physicians. It stands at over 250,000 members — almost a quarter of American physicians — and it has a House of Delegates which votes in a way similar to the House of Representatives in Congress. This also means that not all physicians in the AMA are on the same page, as exemplified by internal debates over support for the ACA.

The Recovery Plan

For the first time in almost 3 years since the start of the COVID-19 pandemic, the AMA recently started an organized lobbying effort on Capitol Hill. Although the AMA keeps a team of lobbyists in DC, this recent push covered by NPR features doctors speaking with Congressional aides and representations themselves. A new set of Republicans bent on cutting Medicare are likely the target of this push — physicians are concerned that cutting Medicare will mean less reimbursement for medical services given to seniors under the Medicare program.

To encourage quality of care, Medicare operates the Quality Payment Program (QPP), which provides physicians with incentives and higher reimbursement for favorable measures of clinical quality. The AMA was successful in pushing for flexibilities to this program during the COVID-19 emergency, which allowed physicians to get these rewards easier.

Late last year, the AMA and a coalition of other healthcare organizations managed to reduce a proposed 8.5% cut to Medicare payments. The AMA holds that over 2001-2021, the cost of running a medical practice rose 39% while Medicare payments to physicians fell over 20%. The argument to lawmakers? Cut Medicare and doctor’s can’t afford to keep their doors open to take care of patients.

At the moment, the long goal for the AMA is some way to tie adjustments in Medicare payments to doctors against inflation and to make changes in payment amounts less extreme.

Another area of concern for the AMA is prior authorization reform. To control the cost of medical services for a population, insurers use the prior authorization process to check whether medical services are deemed necessary. For this, physicians must submit a request to the insurer, and it is not uncommon for these requests to be denied. If denied, the physician must try file a new request or the patient is on the hook for paying entirely out-of-pocket.

The AMA is pushing for rules that would increase transparency and standardization of these prior authorization processes to reduce the complexity and administrative cost of this process.

Among other issues, the AMA is also pushing to ensure that Medicare reimburses equal amounts for telehealth services and working to hammer out policy to prevent stigmatization of physicians pursuing mental health treatment for burnout. Another notable push, which was discussed on last week’s issue of this newsletter, is the AMA’s work to prevent nurses and physician assistants from having increased authority to practice medicine.

The full “progress report” on the AMA’s plan is available here.