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The American Medical Association (AMA) House of Delegates gave a thumbs up to a "public option" -- with caveats -- but a thumbs down to marijuana legalization at the final day of its virtual special meeting.

The delegates first debated a about ways to maximize health insurance coverage for lower-income people. The report said that "The Council is aware of the growing interest within the House of Delegates for our AMA to support a public option" for those who can't afford health insurance coverage. "However, the term 'public option' has several different meanings, and blanket support for a public option without safeguards in place could have negative consequences for physicians and their practices."

The council recommended that only those without access to affordable employer-sponsored coverage should be eligible for premium tax credits or help with insurance costs; "otherwise ... physician revenues could be significantly impacted, especially if payment rates ... are tied to or guided by Medicare and/or Medicaid payment rates." The council also suggested that "public option proposals should not require provider participation, and/or tie a provider's participation in Medicare, Medicaid and/or any commercial product to participation in the public option."

Debate Over Terminology

Michelle Berger, MD, of Austin, Texas, speaking for the Texas delegation, proposed that the words "public option" in some of the recommendations be replaced with the words "a plan to expand coverage for the uninsured" and then just "this coverage." "The purpose of our amendment... is to include any changes in coverage and different points of view" on what insurance expansion should look like, "so we don't have to keep returning to the House and amending our policy for the politically popular 'program du jour,'" she said.

Michael Simon, of Wappingers Falls, New York, speaking for the American Society of Anesthesiology, liked that idea. "The term 'public option' has been fraught with concern, meaning different things to different people ... Should we pass this as it is, the press will simply say that the AMA supports a public option. The fine print will be left out and we cannot risk that; there is too much is at stake."

Texas delegation chair David Henkes, MD, of San Antonio, agreed, warning that if the recommendations were approved without the change, "I predict this will result in a great loss of a number of AMA members."

But Rod Trytko, MD, of Spokane, Washington, an author of the report, disagreed. "Today, healthcare for too many is not affordable," he said. "We shouldn't run from the term, but embrace it." Ryan Englander, of Farmington, Connecticut, speaking for the Medical Student Section, agreed with Trytko.

"The incoming administration will be putting forward a public option for Congress's consideration. Our AMA will be engaged to one degree or another in those discussions. The question is what that role will be," he said. "By refusing to mention the term 'public option,' we limit our ability to maximally participate in one of the most important discussions of health system reform in the 21st century.

Bill Golden, MD, of Little Rock, Arkansas, speaking for the American College of Physicians, pointed out that the Texas amendment "limits its comments to the uninsured. It would make the report silent on the underinsured. We have a great problem in this country with patients on 'skinny' plans. That harms access and adversely affects patients and physicians. We strongly oppose this amendment."

In the end, the Texas amendment failed by a vote of 184-308, and the report was approved without it.

Concerns About Cannabis

Delegates also debated a report from the AMA Council on Science and Public Health regarding the public health impacts of cannabis legislation. The report noted that current AMA policy "categorizes cannabis as a dangerous drug and public health concern" and believes that its sale to adults "should not be legalized," and that "With respect to criminal penalties, our AMA believes that public health-based strategies, rather than incarceration, should be utilized in the handling of individuals possessing cannabis for personal use. A plea of cannabis intoxication should not be a defense in any criminal proceedings."

The report recommended adding to AMA policy a suggestion for states that have already legalized cannabis to "regulate retail sales, marketing, and promotion intended to encourage use; limit the potency of cannabis extracts and concentrates; require packaging to convey meaningful and easily understood units of consumption, and require that for commercially available edibles, packaging must be child-resistant and come with messaging about the hazards about unintentional ingestion in children and youth."

The report also affirmed that the AMA "will advocate for stronger public health messaging on the health effects of cannabis and cannabinoid inhalation and ingestion, with an emphasis on reducing initiation and frequency of cannabis use among adolescents, especially high potency products; use among women who are pregnant or contemplating pregnancy; and avoiding cannabis-impaired driving;" and that the AMA "supports social equity programs to address the impacts of cannabis prohibition and enforcement policies that have disproportionately impacted marginalized and minoritized communities."

Michael Medlock, MD, of Lexington, Massachusetts, speaking for the New England delegation, offered an amendment removing the AMA's policy against marijuana legalization. "By democratic vote, we express the will of the House of Delegates. By democratic vote, patients have already expressed their will in an accelerating wave of marijuana legislation," he said. "If our patients choose to partake, we need to promote responsible marijuana use. To do that we need need research and regulation ... and a strong regulatory environment that will keep marijuana out of the hands and brains of our children. "

Social Trends and Scientific Evidence

Justin Magrath, of New Orleans, Louisiana, who was speaking for the Medical Student Section, agreed. "Our house of medicine just voted to recognize racism and police brutality as public health problems, and one of greatest manifestations of the criminal justice system ... is the war on drugs," he said. "Incarceration ruins families and decimates economic opportunities ... Let's have real action on this and change our policy."

Anna Yap, MD, of Los Angeles, speaking for the American Association of Public Health Physicians, said that "As a practical matter, a marijuana prohibition is not enforceable" and added, "It's no longer a choice between legalization or not, but it's now a choice in how we speak about it and how we protect patients."

Vivian Pender, MD, of New York City, the president-elect of the American Psychiatric Association (APA) who was speaking for the section council, disagreed. "The APA delegation is against this amendment," she said. "There is no scientific evidence that cannabis is in any way beneficial for the treatment of any psychiatric disorder. In contrast, current evidence supports at minimum a strong association of cannabis use with the onset of psychiatric disorders, and adolescents are particularly vulnerable to harm, given the effects of cannabis on neurological development."

Mark Bair, MD, of Highland, Utah, speaking for the PacWest conference, echoed Pender. "Cannabis is still illegal federally despite what states have decided to do," he said. "There have been documented, multiple public health risks that include increased automobile accidents, overdoses, and markedly increased phone calls to poison control centers. As emergency physicians, we are seeing more and more complications. We don't need to be bowing to social trends; we should stick to the policy as decided and stay with the science, not the social trend."

The amendment narrowly failed on a vote of 227-201, and the rest of the report was approved.

The association also voted to add a new member section -- Private Practice Physicians. The section will "be dedicated to advocacy on private practice physician policy issues, provide leadership development and educational opportunities for medical students and young physicians, and monitor trends and issues that affect private practice," according to , which also noted that a recent AMA survey found that physicians who own their own practices are outnumbered by those who are working as employees of someone else.

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