AMA House Tackles Medicare Financing Reform, Public Health Topics

Even as stakeholders across the country awaited the U.S. Supreme Court's ruling on the Patient Protection and Affordable Care Act, the AMA House of Delegates voted during its 2012 annual meeting here to direct the AMA to "refine its policy regarding Medicare financing options, including a defined contribution program that would allow beneficiaries to purchase traditional Medicare or a private health insurance plan through a marketplace of competing health plans."

The measure, a substitute resolution offered by the AMA Reference Committee on Medical Service, further calls for the AMA to "consider mechanisms to adjust contributions in order to ensure that health insurance coverage remains affordable for all beneficiaries."

According to the reference committee report (pp. 19-21 of 44-page PDF; About PDFs), the substitute measure is intended to give the AMA Council on Medical Service "a foundation upon which to move forward with policy development necessary to ensure future Medicare viability."

In adopting the substitute, delegates backed away from language in the original resolution (pp. 1-4 of 151-page PDF; About PDFs) that called for the AMA to "support transitioning Medicare to a premium support system" in which all beneficiaries would receive a set amount from the federal government to purchase traditional Medicare or a private health insurance plan. That wording, in turn, was taken from recommendations in a report (pp. 22-33 of 96-page PDF) prepared by the AMA Council on Medical Service that was withdrawn just days before the AMA meeting began.

In testimony before the reference committee on June 17, council chair Thomas Sullivan, M.D., explained that the report was withdrawn because council members recognized a need to develop a more comprehensive document after receiving initial comments on the report via the annual meeting's virtual reference committee process and other means. He urged that the measure be referred so additional work could be done to address the complex policy issues involved in any proposal to reform the Medicare program.

During his turn at the microphone, AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash., said that he was sensitive to those who had expected to be able to testify on the council report during the reference committee hearing. However, because the report had been withdrawn before the meeting convened, many delegates had not anticipated discussing premium support for Medicare. Thus, resurrecting the issue in a late resolution could leave some delegates ill-prepared to testify on the topic.

Furthermore, he said, given that the council itself acknowledged it had more work to do on the report, adopting a resolution that included the same proposals would preempt the chance to expand and strengthen the council document.

Finally, Stream pointed out that the issue of premium support -- read: tax credits -- for Medicare is a highly partisan topic, particularly in the midst of a hotly contested presidential campaign in which taking a stand either way could be construed as siding with one or the other presidential contender. "We should not be supporting specific policy at this time," he said. "It's just too divisive."

AMA delegates also considered numerous public health issues, including taxes on sugar-sweetened beverages, sales of tobacco products in pharmacies and support for breastfeeding.

The AMA Council on Science and Public Health issued a report (pp.62-79 of 143-page PDF; About PDFs) examining whether the scientific literature supports the claim that limiting consumption of beverages with added sweeteners can improve health outcomes and, if so, whether a tax on these beverages would be an effective national public health strategy to reduce that consumption.

Although the council acknowledged that, by itself, such a tax is unlikely to have a significant impact on obesity and other adverse outcomes, it said taxation could be one element of a more comprehensive plan to curb obesity and its sequelae. Moreover, levying such a tax could fund local, state and federal governments' efforts to combat obesity and improve public health.

The report's reference to a tax sparked immediate concern, with one delegate who testified during the June 17 hearing of the AMA Reference Committee on Public Health observing, "The American people do not need the AMA coming out in favor of taxes; the American people need the AMA to envision healthy lifestyles." Another pointed out that such a tax would be regressive, unfairly singling out lower-income populations whose access -- both physical and financial -- to healthier beverage alternatives is often limited.

Not so fast, said Robert Gilchick, M.D., M.P.H., a delegate from the American College of Preventive Medicine and a member of the AMA council. The report neither supports nor opposes such a tax, he pointed out. Rather, "it states that the AMA recognizes that a tax on sugar-sweetened beverages is one strategy that could be used among a variety of strategies to impact the obesity epidemic."

AAFP President-elect Jeffrey Cain, M.D., of Denver, told delegates that the AAFP has clear policy that "supports taxation of sugar-sweetened beverages for the purpose of reducing overconsumption as a method of both improving the health of the public and combating the obesity epidemic."

Furthermore, he noted, the AAFP agrees with the council report's call for any tax monies so raised to be directed toward programs to improve the health of the public.

It's also important, said Cain, to ensure that the tax amount levied is sufficient to actually reduce consumption of these beverages, a supposition that the American Beverage Association disputes.

In its report (pp. 5-7 of 34-page PDF; About PDFs), the reference committee acknowledged additional testimony indicating that obesity is multifactorial and that limiting sugar-sweetened beverages (SSBs) alone is "unlikely to stop or reverse the obesity trend." However, the report added, limiting consumption of these beverages "is a simple way to reduce intake of added sweeteners without compromising the nutrient adequacy of the overall diet."

"Given the strong and consistent associations of SSBs with body weight and several cardiometabolic conditions, limiting consumption of SSBs is likely to improve health outcomes," said the report. Delegates agreed, adopting the report's recommendations

Two tobacco-related resolutions also prompted spirited testimony. Both measures sought to curb sales of tobacco products in pharmacies -- a position the Academy has taken for years -- but used divergent, carrot-versus-stick approaches. One called for the development of a recognition program for pharmacies that voluntarily agree to quit selling these products, with widespread dissemination of that recognition. The other directed the AMA to work with Federation members and other stakeholders to publicly denounce the practice and to seek legislative and regulatory aid in getting these products off pharmacy shelves.

In his testimony, Cain pointed out "the irony of selling an addictive poison on one shelf and the antidote on another."

Russell Kridel, M.D., a member of the Council on Science and Public Health, cast the issue in the context of pharmacists' bid to gain some degree of physicians' prescriptive authority, saying, "I don't know any docs who are selling cigarettes in their offices."

Delegates ultimately adopted (pp. 13-14 of 34-page PDF; About PDFs) a measure that combined the two resolutions.

Similarly, delegates considered two separate resolutions on support for breastfeeding, adopting the tenets of both and blending them into existing AMA policy (pp. 14-16 of 34-page PDF; About PDFs).

AAFP alternate delegate Anne Montgomery, M.D., of Spokane, Wash., who worked to develop the Academy's breastfeeding policy, joined Cain in speaking in favor of the measures. Their testimony was based on AAFP policy, which recommends that "all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life. Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year."

The amended AMA policy on breastfeeding now largely mirrors that of the AAFP, including calling on hospitals to fully support a mother's decision to exclusively breastfeed her infant.