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Expanding Medicare to include people ages 60 to 64 remains a divisive issue among members of the American Medical Association House of Delegates.

In total, "1.7 million Americans between ages 60 and 64 remain uninsured; another 3.8 million are on Medicaid," Rajadhar Reddy, an alternate delegate and medical student from Houston speaking on behalf of the Medical Student Section, said at a meeting of the AMA reference committee on medical service held during the AMA's annual meeting. "We have a unique opportunity in this momentous time in health reform to either expand or increase coverage for another 5.5 million people through this proposal." Reddy was explaining the section's proposal "that our American Medical Association advocate that the eligibility threshold to receive Medicare as a federal entitlement be lowered from age 65 to age 60."

The plan "would also heavily benefit early retirees -- disproportionately those with lower socioeconomic status -- who often retire for health reasons," he continued. "Given the extreme timeliness of this proposal to discussions occurring in Congress this summer, we think that many physician delegates would express support" for the idea, but because time is getting tight to get legislation through Congress with the thin Democratic majority in the Senate, "we cannot delay consideration."

Reimbursement Concerns

Sherif Zaafran, MD, an alternate delegate from Texas who spoke for his delegation, disagreed. "While we support the intent of expanded access to care, we caution that it must not be done in a way that affects physicians' ability to provide care," he said. "Medicare for many specialties reimburses at numbers significantly below commercial rates, and this cost-shifting from commercial payers to government payers in an environment where Medicare is already having funding difficulties will only increase downward pressure on physician compensation as the pool of patients entering into Medicare would increase significantly without the possibility or probability of adequate commensurate funding."

Ted Mazer, MD, a delegate from California, said his delegation supported referring the resolution to the AMA board of trustees for further study. "The CMA [California Medical Association] and the AMA strongly support universal coverage and access to care, but many physicians are quite concerned about the extension of the current Medicare fee schedule to additional patients, when physicians are already struggling to maintain financial viability under the current program, not to mention the 4% to 13% cuts that are pending next year," he said. "Given the low probability of Congress adopting changes to Medicare eligibility this year, CMA believes that it's imperative that AMA take the time to perform a thorough analysis of the pros and cons of expansion of the program."

Former AMA president Daniel "Stormy" Johnson, MD, who described himself as "a longstanding Medicare beneficiary and older than dirt," also spoke against the resolution, emphasizing that Medicare "is not actuarially sound. It's a pay-as-you-go system that depends on the number of people paying into the program versus the beneficiaries like myself, and the number of folks paying in relative to the number of beneficiaries continues to decrease because people like me are living too long." Therefore, reducing the eligibility age "will further undermine the financial stability of the program," said Johnson, an American College of Radiology delegate who is in his mid-80s.

A Third Option

Gary Floyd, MD, who spoke on behalf of the House of Delegates' Council on Legislation, argued for reaffirming existing AMA policy instead of passing the resolution. Thanks to the passage of legislation to help people during the COVID-19 pandemic, "effective this year and next year, the ACA's [Affordable Care Act] premium tax credits are more generous, and the 'subsidy cliff' has been eliminated," he said. "AMA has long been in support of these improvements, and we believe they should be made permanent ... We now have to take advantage of this unique opportunity to fulfill the goal of the ACA to cover the uninsured, including those aged 60 to 64."

Telehealth was another area of controversy, with delegates going back and forth on a resolution co-sponsored by nine state delegations asking the AMA to "conduct or commission a study on the effect that telemedicine services have had on health insurance premiums." While lowering the Medicare eligibility age remains controversial, most members were more in agreement on one resolution related to telehealth.

Aaron Elkin, MD, an alternate delegate from Florida -- one of the cosponsoring state delegations -- noted that during the pandemic, many insurers covered telemedicine visits, and some even paid for it at rates similar to in-person visits. But insurers have fought efforts to force them to continue doing so once the pandemic ends. "They're claiming, 'Hey, you know, we're going to cover telemedicine but that's going to increase the cost of care and therefore it's going to increase premiums,'" Elkin said. "So what we need is data ... so our resolution asks the AMA to conduct a study and research to be able to give us the data" on the issue and report back at the next meeting.

High Price-Tag

Chris Bush, MD, an alternate delegate from Michigan, speaking for himself, said he was struck by the high price-tag for the study -- an estimated $260,000. "I think this data could be obtained from other sources, and it seems to be more of a regional or state-by-state issue," he said. "I don't know how a national report from the AMA really could be could be helpful for those local areas and local practices."

Patrice Burgess, MD, a delegate from Idaho who spoke on behalf of the delegates' Council on Medical Service, recommended that the resolution be referred to the board of trustees for a decision. "I understand the desire for more data, but I think it's important to look at how much the AMA wants to invest in getting that data," she said.

Jacqueline Fincher, MD, spoke on behalf of the American College of Physicians in support of the resolution. "The GAO [Government Accountability Office] recently that showed that it was very important to continue parity of telehealth payments, and we certainly support not only the audio visual, but the audio only" visits, she said. "This is critical to our patients, as we have found this year, and we know that there are good downstream effects in terms of preventing patients from having to go to the emergency room or being hospitalized for things that can be dealt with, easily, by telehealth."

The reference committee will meet over the next few days to issue recommendations on each resolution; the House of Delegates will vote on the recommendations during its general session, which began on Friday and continues on Monday.

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