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The American Medical Association (AMA) House of Delegates endorsed subsidizing healthcare for undocumented immigrants on the Affordable Care Act (ACA) exchanges during their interim meeting in Orlando, Florida, on Monday.

As of June, six states and the District of Columbia regardless of immigration status, and as of Nov. 1, some may be eligible for coverage on the ACA exchanges.

On a related question of whether to support extending the enhanced ACA subsidies overall, the House also voiced its support, with some changes.

However, not all delegates were on board. Jordan Warchol, MD, MPH, a delegate from Nebraska, said she worried that passing such a resolution right now wasn't prudent.

Given the current political climate and that Warchol, who spoke on her own behalf, suggested that the House wait a few months.

"Passing this policy today ... may unnecessarily put a target on the back of this organization at a time that we really do not want that," she said, arguing that if the media got wind of the resolution's passage, it might negatively impact the association's priorities for the next 4 years.

The resolution was not "bad policy," she stressed, calling it a "reasonable" statement for the AMA to make, but for the optics and the timing.

A committee focused on medical service and practice advocacy appeared to draw a similar conclusion, suggesting that the policy statement be referred for study.

However, on Monday afternoon, the House overruled the committee's recommendation, and in a vote of 362-259, adopted the resolution.

Luis Seija, MD, a delegate for the Minority Affairs Section, the primary sponsor of the policy statement, argued that no further investigation was necessary, as the resolution included nearly 20 different references to studies backing the concept.

"The evidence shows that uninsured individuals, particularly those in undocumented communities, experience higher rates of preventable illness or chronic disease and worse overall health outcomes," Seija said. "Subsidizing health insurance would allow undocumented immigrants to access care when they need it, not just in emergencies, leading to healthier communities overall, as well as a more inclusive, equitable, and efficient healthcare system."

Frank Zhou, a medical student speaking on behalf of the PacWest Conference, also argued against referring the statement for further study.

"This policy is simply good for everyone and all stakeholders involved," Zhou said, noting that it's good for patients, because they get better healthcare, and good for the healthcare system, because it keeps immigrant patients from relying on emergency departments, which not only lowers costs, but reduces boarding.

It's also good for physicians, he added. "When undocumented folks come and seek care and actually have insurance, then we get compensated ... And I think we like getting paid for the work that we do."

Zhou also pointed out that undocumented immigrants pay more than $90 billion in taxes every year. "They deserve to be able to buy insurance on the ACA marketplace ... like everyone else with these subsidies," he said.

Other delegates disagreed.

Deepak Kumar, MD, a delegate from Ohio speaking on his own behalf, said as a legal immigrant he opposed the resolution. When his wife was immigrating to the U.S., he had to show proof of insurance without any support, and demonstrate that his wife would not "be on the dole," he said. More recently, his daughter married a Canadian, who also had to prove "evidence of insurance with no subsidies."

"So, if you want to provide for undocumented individuals ... some sort of subsidies, that needs to be provided to legal immigrants as well," he said.

James Milam, MD, a delegate from Illinois who also spoke for himself, shared Kumar's concerns, pointing to his conflict of interest: "My wife is on the exchange."

He argued that any coverage gaps experienced by American citizens should be addressed before the nation extends those subsidies to undocumented people.

"Please understand, people, I am not unsympathetic to undocumented folks getting care, but I have to take care of my own family first," Milam said.

As for the concerns about optics, Katrina Saba, MD, a pediatrician and California delegate speaking on her own behalf, urged the committee not to wait to adopt the resolution. "If there is a target on the AMA's back, I think we should wear that target proudly," she said.

Carl G. Streed Jr., MD, MPH, a delegate for the LGBTQ+ Section, agreed. "We have sufficient evidence to show this is a critically important issue, and I'm not willing to shirk just because of a headline that may or may not happen," he said.

A separate resolution on whether to support the extension of the enhanced ACA subsidies, which expire at the end of 2025, was also approved.

However, an amendment to that policy statement eliminated a provision calling for the AMA to "immediately initiate or substantially invest in a focused grassroots campaign" around such an extension.

Sherif Z. Zaafran, MD, a delegate for the Texas Medical Association, who introduced the amendment, argued that while his delegation supports extending the tax credits, it did not want any other effort to distract from what it views as AMA's primary priority: Medicare payment reform.

"We need to be focusing on the one item that is absolutely essential for all of us, which is having a Medicare economic inflationary index applied to our Medicare payments so that we're not getting cut on an annual basis," Zaafran said. "If we dilute that effort by having multiple other asks, then we lose that effort."

While delegates from the Medical Student Section, the Resident and Fellow Section, the American Academy of Pediatrics, and the Massachusetts delegation opposed the amendment, their concerns were overruled, and the final amended resolution was adopted in a vote of 507-51.

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