The AMA's cure for the uninsured

To many on the left, the AMA's longstanding opposition to anything that smacks of government-controlled healthcare is little more than obstructionism. The latest blast comes from documentary filmmaker Michael Moore, who in Sicko ridicules the doctor group for its stance against Medicare and "socialized medicine" more than 40 years ago.

Times change, though, and so has the AMA, at least somewhat. If its opposition to national health insurance or a single payer system is as strong today as it's ever been, it's no longer willing to be seen as simply obstructionist or indifferent. The run-up to the 2008 elections has only heightened that unwillingness, especially on the hot-button issue of Americans without health insurance.

Late last month, the AMA announced with great fanfare its three-year, multimillion-dollar campaign to cover the uninsured, now at 47 million. Using a variety of media, including print and broadcast, the campaign will use real people to dramatize their plight.

Counting on core assumptions

The AMA plan-parts of which have been around for years-is spelled out in a 24-page proposal, available on the campaign's website ( http://www.voicefortheuninsured.org). At its center is a system of refundable tax credits, adjusted by income, to help lower-income people purchase health coverage, whether individually or through an employer-sponsored program. As for people in the higher income brackets, they may qualify for some subsidies but they'll lose their federal income tax exclusion for employment-based benefits-which means that the value of those benefits must henceforth be reported to the IRS as taxable income.

In laying out its ideas, the AMA makes certain assumptions, which may or may not be true. The first is that individual buyers of health insurance can be trusted to make smart choices. Perhaps, but to do so they'll need the right tools to gauge cost and quality, and, right now at least, those tools seem to be missing. The second is that coverage purchased on the individual market will be as affordable as group coverage. That also may be true, as long, that is, as "people are willing to make do with a more limited array of benefits when buying health insurance for themselves," something the AMA itself acknowledges. The third assumption is that value-conscious consumers will drive down the overall cost of coverage. Again, good if true, but surveys of consumer-directed plans report fewer medical visits among users-which suggests that patients may be delaying or skipping care they really need. Finally, the AMA is betting on the political acquiescence of middle- and upper-income voters-the very groups who could end up paying more in federal income taxes. Of everything the AMA is counting on, that may be the biggest untested assumption of all.

The organization isn't taking a hard line, however. "We know we're going to have to compromise," says Nielsen, "but the country has got to start with a proposal that can get real action."

A pragmatic position, certainly. Still, if the Democrats sweep next November, that proposal may include more government intervention than the AMA is comfortable with.