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The Schizophrenia of the AMA
by Hal Scherz 

In the aftermath of the Obama presidential election, healthcare reform became an intensely debated political issue, and the American Medical Association (AMA) had a difficult time deciding their position on the Affordable Care Act (ACA, Obamacare). In 2009, the AMA initially announced that they could not support President Obama’a plan for healthcare reform. One week later, they abruptly reversed course, proclaiming that they were completely behind his plan; support which proved critical for passage of this bill. Two weeks ago, the AMA announced their version of a premium support plan for Medicare, which would be introduced and debated during their annual conference in Chicago. Then, just one week later, they again did an “about face” and have taken this issue off the agenda, avoiding a controversial and potentially embarrassing situation. In politics, this is called “flip-flopping”. 

These policy reversals without a clear rationale, raises questions about an organization which proclaims itself to be the “spokesman” for doctors and for the medical profession. One has to assume that external pressures may have forced such decisions and herein may be the crux of the issue. The AMA is conflicted. Their dilemma stems from self- preservation, because the majority of their revenue (in excess of $70 million annually) is derived from a monopoly over medical coding which the Federal Government has granted them. They are in a precarious situation because taking a position contrary to Obamacare, jeopardizes their franchise. 

The AMA’s problems have deepened because they are not what they purport themselves to be- the spokesman for the community of physicians. How can they be when only approximately 10% of the practicing physicians in the US are members? In contrast to the 1960’s when over 75% of doctors belonged to the AMA, their influence in the medical community has waned considerably, in part because they are out of touch with the views of practicing physicians. Obamacare is a perfect example. A recent Jackson Healthcare survey reported that 70% of doctors felt that it deserved a failing grade and 55% felt that it should be repealed- clearly not the AMA position. Only 12 % of doctors thought that the ACA would fix healthcare. 

In an effort to regain lost credibility amongst physicians, and to become more relevant, the AMA did what most people expected them to do- they “pivoted”. This involved “tough talk” and taking some oppositional positions against the “bad” parts of Obamacare, attempting to make everyone forget that they were partly responsible for this law. 

One part of Obamacare that the AMA has recently blasted is the Independent Payment Advisory Board or IPAB- one of the most onerous parts of the ACA. It is an unelected, unaccountable board, charged with the singular task of reducing Medicare spending. This can only be done by reducing physician reimbursements until 2020, because hospitals managed to negotiate an exemption until then, but not doctors. Surely an effective voice for physicians could have had some influence when it came to this part of the legislation? Unfortunately, the reality is harsher than the rhetoric. In newly released documents obtained by the House Energy and Commerce Committee, there is evidence that the AMA disagreed with the framework of IPAB, but did not “totally reject the concept of an advisory board”. So the IPAB remained and the damage to physicians was done, no thanks to the AMA. 

The AMA hopes to appear as a broker in the Medicare issue, releasing a plan of its own, which would attempt to address the impending insolvency of the program by instituting a premium support plan, not too dissimilar to the Paul Ryan plan. Just as quickly as this plan was announced, it was pulled back. Premium support for Medicare is a GOP issue during this presidential election, so once again the AMA executed an “about face”, not dissimilar to what occurred back in 2009. One can only speculate that an AMA position in favor of Medicare premium support was not looked upon favorably by the Obama White House. 

The AMA needs to decide who they represent and what their current purpose is. There is little doubt that self -interest is their primary goal. However, as an organization that purports itself as the representative of physicians, they have left considerable doubt that they take this role seriously. AMA president elect Jeremy Lazarus provided some insight as to what the AMA considers their role to be when he told Inside Health Policy “the AMA’s support for the health reform law reflects our role as a leading voice for covering the uninsured “. Although covering the uninsured may be a problem, the main obligation of the AMA is to physicians, and their continued blind, unwavering support for the ACA puts them at odds with their constituency. The ACA will have a devastating impact on physicians and the AMA has failed to protect them, leaving physicians without an advocate. The AMA cannot serve 2 masters. They must choose who they represent. Perhaps it is time for the AMA to step aside and make way for another organization more interested in protecting the needs of doctors; one that is not conflicted. 

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