REPORT OF THE BOARD OF TRUSTEES

B of T Report 2 - I-99

Subject:	Strategies for Increasing Access and Expanding Health Insurance Coverage

Presented by:	D. Ted Lewers, MD, Chair

Referred to:	Reference Committee A
		(Jerome Bobruff, MD, Chair)

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Increasing access and expanding coverage have long been a priority for the AMA, and during the past year the AMA had an unprecedented response to the troubling growth in the number of the uninsured.  Two key events led to the preeminence of this issue during 1999.  First was the adoption by the House of Delegates of Council on Medical Service Report 9 (A-98), which outlined a broad strategy for private sector insurance reform that would increase choice and potentially expand coverage for patients by making individually selected, purchased and owned health insurance both affordable and available as an alternative to employer-sponsored coverage.  Second, during her tenure as AMA President, Nancy W. Dickey, MD, brought access and coverage to the forefront of AMA advocacy.  In December 1998, Doctor Dickey spoke at the National Press Club and challenged the press, members of Congress, and other policymakers to make access and coverage priority issues. 

In this report, the Board of Trustees summarizes AMA policy development and refinements, and highlights the legislative and regulatory developments, targeted outreach and coalition building activities, and communications strategies that have been undertaken during 1999 in an effort to achieve the AMA’s vision for increasing access and expanding coverage.

POLICY DEVELOPMENTS AND REFINEMENTS

Extensive AMA policy favors increasing access to health care and expanding coverage for health care expenses.  In the public sector, the Medicaid program serves as a “safety net” for the poor who would otherwise be uninsured, and the newly created Children’s Health Insurance Program (CHIP) provides coverage for children in families with incomes above the Medicaid eligibility limit.  Recent changes in the Medicaid application process and early difficulties in CHIP enrollment are addressed in Policy H-290.982 (AMA Policy Compendium).  CMS Report 5 (I-99), which is before the House of Delegates at this meeting, provides a status report on the Medicaid program, and describes Policy H-290.982 and other Medicaid and child-related policies in detail.

In addition, the Council on Medical Service has been aggressive in developing and refining AMA policy for private sector health insurance reform as presented in CMS Report 9 (A-98) and documented in Policy H-165.920.  In adopting the recommendations of CMS Report 2 (A-99), which provided an update on increasing access for the uninsured, the House of Delegates established policy opposing new health benefit mandates unrelated to patient protections, which jeopardize coverage to currently insured populations.  CMS Report 2 (A-99) also described characteristics of various groups of the uninsured, and concluded that AMA policy supporting individually owned insurance (Policy H-165.920) remains relevant for addressing the coverage needs of many of the currently uninsured.  Also at the 1999 Annual Meeting, CMS Report 5 discussed the voluntary choice cooperative concept necessary to implement the AMA’s private sector vision for individually owned insurance. 

Policy H-165.920 contains a broad set of recommendations for reforming private sector health insurance in a manner that increases patient choice and allows for expanded coverage through individually selected, purchased and owned insurance, rather than employer-sponsored coverage.  The policy calls for legislation that would allow individuals to receive tax credits for the purchase of health insurance.

Policy 165.882 includes 11 recommendations for increasing access for children including a preference for enabling children to obtain private coverage rather than being placed in Medicaid.  The policy also contains four recommendations for improving access for uninsured persons of all ages, including the creation of some type of voluntary choice cooperative that would allow individuals to pool risk and receive group insurance rates outside of an employer relationship.

LEGISLATIVE AND REGULATORY DEVELOPMENTS

Several recent legislative and regulatory developments emphasize increasing access and expanding coverage, including some that would provide individuals with a tax credit to purchase health insurance.  In addition, the AMA continues to be involved in assuring that public sector programs fulfill their safety net function.  

Legislative Developments

A number of legislative proposals were introduced in the 106th Congress and many continue to be under development that would expand patient choice and access to health insurance by restructuring the tax code so that individuals could receive a tax credit toward the purchase of health insurance.  The AMA reviewed proposals by Reps. Dick Armey (R-TX) (H.R. 2362), Charlie Norwood (R-GA) (H.R. 1136), Pete Stark (D-CA) (H.R. 2185), and John Shadegg (R-AZ) (H.R. 1687), pursuant to requests of the legislators.  Although many proposals have been gaining popularity with interest groups and other members of Congress, at the time this report was written none had emerged as significant legislation in terms of leadership support or committee recognition.  

All of the cited bills would amend the tax code to allow individuals without employer-sponsored coverage to receive a refundable tax credit toward the purchase of qualified health insurance coverage, excluding from eligibility those covered by Medicare, Medicaid, and other various federal health insurance programs.  The amounts of the proposed credits varied from $500 to $1200 for each individual and from up to $1000 to $3600 maximum per family.  

Rep. Norwood’s bill would have allowed individuals with employer sponsored coverage to receive a credit up to $400 (and $200 for each dependent) to use for supplementing or improving the coverage under their current policies.  Rep. Stark’s bill would allow advanced payment of the credit to providers of health insurance coverage and would establish an Office of Health Insurance (OHI) under the Department of Health and Human Services to administer the program.  The OHI would contract with insurance carriers in a manner similar to the Federal Employee Health Benefits Program (FEHBP) and would be required to apply premiums on a uniform, community-rated basis.
None of the bills that have been introduced is in complete accordance with AMA policy on private sector insurance reform, yet all seem to take a step in the right direction.  The AMA has communicated this view to these members of Congress, while outlining its specific policy goals for long-term insurance reform and pledging to work with them and all interested parties to find some common ground before we endorse any specific legislation.  

The Council on Medical Service is continuing to further refine the tax credit portion of the AMA’s private sector reform proposal for individually owned insurance.  CMS Report 16 (I-99), which is before the House of Delegates at this meeting, includes a preliminary examination of the economic issues related to evaluating alternative proposals for providing individuals with a tax credit for the purchase of health insurance.

Federal Regulatory Activities

Throughout 1999, the AMA has continued to promote policies to increase access for the uninsured to the Clinton Administration, including the White House, the Department of Health and Human Services (HHS), and the Health Care Financing Administration (HCFA).  These communications have emphasized the need for private insurance market reforms such as tax credits and voluntary choice cooperatives as well as public sector improvements in Medicaid and CHIP.  Highlights of federal regulatory activities include the following:

•	In comments to HCFA on Medicaid managed care, the AMA emphasized the need to maintain Medicaid enrollees access to the public health safety net of providers that has traditionally provided their care but may be denied access to these providers due to managed care contracting decisions.  In addition, the AMA has worked with HHS on the issue of maintaining access to critical safety net providers.

•	In January, the Council on Medical Service met with HCFA staff to discuss Medicaid financing and CHIP implementation issues, which led to the development of CMS Reports 5 (I-99) and 2 (A-99).

•	The AMA has emphasized in communications to the White House and HCFA that a need exists to improve outreach to women and children who are eligible for Medicaid coverage, but who are not enrolled in the program.

TARGETED OUTREACH AND COALITION-BUILDING

The AMA also has conducted significant targeted outreach to business organizations and employers to promote AMA policy on increasing access and expanding coverage.  Specific activities include the following:

•	In December 1998, Doctor Dickey’s speech at the National Press Club launched a national “Physicians Work Group on Universal Coverage” (the Work Group), which included the AMA, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Emergency Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians—American Society of Internal Medicine, and the American College of Surgeons.  Early in 1999, the Work Group developed a Joint Statement of Principle supporting a common goal of working toward enabling every American to have health insurance.
•	The AMA hosted a national Health Sector Assembly in October 1999.  Improving access to health insurance coverage was the topic of this first Health Sector Assembly, which was convened to enhance the AMA’s leadership role on matters related to health.  Participants represented diverse thought leaders and policy makers in key health sector organizations and fields of work.

•	In February 1999, the Executive Committee of the AMA Board of Trustees met with the leadership of the U.S. Chamber of Commerce, the nation’s largest association of business interests, to discuss health insurance reform, with an emphasis on the AMA’s policies on individually owned and selected health insurance and increasing access for the uninsured.  The discussions were productive and an AMA staff task force was created to follow-up with Chamber staff.  The AMA and Chamber task forces have met several times to discuss the uninsured and increasing access through the use of mechanisms such as tax credits and voluntary choice cooperatives.  In October 1999, the Chamber sponsored a Policy Forum on the Uninsured in Washington, DC, in which the AMA participated.  Discussions with the Chamber will continue into the year 2000, with the goals of reaching consensus on proposals to increase access to the uninsured.

•	AMA leadership and staff continue to conduct targeted outreach to individual employers and their health benefits staff to discuss AMA policies to promote patient choice and increase access for the uninsured, including outreach to corporations such as 3M, Xerox, Motorola, and Baxter International.

•	AMA senior staff in Washington met with staff of the National Federation of Independent Business, which represents small employers of 50 or fewer employees, to discuss efforts to increase access to health insurance, particularly for employees of small businesses. 

•	AMA staff presented the AMA goal of increasing access and plan for expanding coverage to various employer health care purchasing coalitions across the country, including the Buyers Health Care Action Group in Minneapolis, the Washington Business Group on Health, and the National Business Coalition on Health.

•	The AMA revised its “Expanding Access” and “Rethinking Health Insurance” advocacy booklets on expanding access and individually owned and selected health insurance and distributed them to over two hundred employers and employer purchasing coalitions throughout the country.

AMA ADVOCACY COMMUNICATIONS

Increasing access and expanding coverage were prominently communicated at the 1999 Annual Meeting with the presentation of the “Is it Good Medicine?” communications campaign, which focused on coverage as an initial key theme.  To highlight the campaign, the AMA placed full-page advertisements in the Chicago Tribune and USA Today on June 21, 1999 that called for increasing access and expanding coverage.
Also during the 1999 Annual Meeting, the AMA Department of News and Information, in a cooperative effort with several state and county medical associations, produced the Hometown Radio Program with access as its sole topic.  This was the second year in a row that the Hometown Radio Program had concentrated on access and coverage.  This year, physician delegates participated in 46 interviews via telephone with their hometown radio stations in 10 states.
On June 14, 1999, the AMA joined other members of the Work Group in a press conference to announce the group’s joint statement and to issue a challenge to the 2000 presidential candidates to make health insurance a top priority.  At the press conference the group vowed to fight for (1) health care coverage for all Americans; (2) health care coverage containing a benefits package; and (3) medical necessity under the benefits package that reflects the generally accepted standards of medical practice, supported by outcomes based-evidence.  

Doctor Dickey represented the AMA during the Work Group press conference, which was just one of many speeches about access and coverage she has delivered around the country.  In all, Doctor Dickey has participated in approximately 25 events during which she urged solutions to the problem of the uninsured or presented the AMA’s proposal for private sector insurance reform.  Notably, she met with the Employee Benefit Research Institute in May 1999, to discuss the AMA plan for individually selected, purchased and owned insurance.  Other members of the AMA Board of Trustees and senior staff have used an additional 25 speaking engagements as an opportunity to promote continued attention on the uninsured and the AMA’s proposal for private sector reform.

Doctor Dickey’s efforts to keep the nation focused on access and coverage has been noted in various media as well.  AMNews featured her prominence on this topic in two separate issues during July 1999.  While Doctor Dickey served as AMA President, the AMA web site’s section “From the President” included a message from Doctor Dickey on the importance of expanding coverage, as well as an excerpt from one of Abigail Trafford's Washington Post columns, which took the form of a letter to Santa Claus telling him what she wanted for Christmas.  Her request mirrors one of the primary tenets of the presidency of Doctor Dickey -- universal access to health care coverage.  Furthermore, one of first postings to this site by current AMA President,
Thomas R. Reardon, MD, reiterated the message of the Work Group by challenging declared candidates for the year 2000 to make expanding coverage a priority.

DISCUSSION

In this report, the Board of Trustees has summarized the key AMA activities that have been undertaken during the past year in an effort to raise national awareness about the uninsured and to promote the AMA vision for reforming the private health insurance system.  The Board believes that these activities are particularly timely as the nation enters a Presidential election year.  The growing number of legislative and regulatory proposals that seek to provide a tax credit for the purchase of health insurance is particularly encouraging at a time when the Council on Medical Service is refining its tax credit proposal so that the AMA will be better able to evaluate and comment on future proposals.  Nonetheless, the Board believes the AMA must remain diligent in its advocacy for private sector insurance reform throughout the coming year. 

RECOMMENDATIONS

The Board of Trustees recommends that the following be adopted and the remainder of this report be filed: 

1.	That the AMA continue to place a high priority on increasing the number of Americans with health insurance coverage.
2.	That the AMA place increased emphasis on advocacy communications during the 2000 Congressional and Presidential election campaigns to promote candidate commitments to address the growing number of the uninsured.  

3.	That the AMA continue to develop and advocate policy in response to the needs of public sector “safety net” programs, particularly Medicaid and the Children’s Health Insurance Program.