CHICAGO — The American Medical Association (AMA) House of Delegates adopted principles today supporting public policy approaches that have the potential to expand insurance coverage to millions of the uninsured, including those who have lost their coverage during the COVID-19 pandemic.

Most notably, the AMA supported auto-enrollment as a strategy to cover many of the remaining uninsured who have coverage options available to them at no cost after any applicable subsidies. As such, eligible individuals could potentially be auto-enrolled in Medicaid/CHIP or zero-premium ACA marketplace coverage. The AMA sees tremendous potential in proposed improvements to the Affordable Care Act (ACA)—as outlined in the AMA proposal for reform—and believes that auto-enrollment in combination with these improvements can maximize coverage gains.

Elimination of the federal individual mandate penalty under the ACA as well as the job losses from COVID-19 have given impetus to alternative approaches to maximize coverage rates. A significant number of uninsured Americans are eligible for no- or low-cost coverage but are not enrolled.  Before the COVID-19 pandemic, nearly 60 percent of the nonelderly uninsured population was eligible for—but did not take advantage of—financial assistance, either through Medicaid or the Children’s Health Insurance Program, or via premium tax credits to purchase marketplace coverage as provided for under the Affordable Care Act. As a result, there is a clear opportunity to auto-enroll many of these individuals in coverage that would be of no cost to them. Auto-enrollment can be an essential tool during the pandemic, as state unemployment programs could be leveraged to identify people who lose their employer-sponsored coverage to get covered in other ways.

The AMA also adopted safeguards to guide the development of proposals that would establish a public option. While ACA improvements, if implemented, could achieve significant coverage gains on their own, the AMA recognized that a public option has the potential to provide patients with more health plan choice.

“A public option should not be seen as a panacea to cover the uninsured. It should not be used to replace private insurance; rather it can be used to maximize competition. With appropriate guardrails, the AMA will examine proposals that would provide additional coverage options to our patients,” said AMA President Susan R. Bailey, M.D.

A public option has the potential to serve as another health plan choice for those only with unaffordable coverage options, many of whom remain uninsured. Significantly, the AMA believes a public option shall be made available to uninsured individuals who fall into the “coverage gap” in states that do not expand Medicaid—having incomes above Medicaid eligibility limits but below the federal poverty level, which is the lower limit for premium tax credits—at no or nominal cost. Individuals who have access only to unaffordable employer coverage would be eligible for financial assistance to purchase coverage on the ACA marketplaces—to purchase either a private ACA marketplace plan, or a future, potential public option. Any public option should compete on an even playing field with private ACA marketplace plans. Similar to what is experienced with private health plans, payment rates under any public option need to be established through meaningful negotiations and contracts. Physician freedom of practice must be maintained and public option proposals should not require physician participation. Public options also should be financially self-sustaining and not receive advantageous government subsidies compared to other health plans.

“The AMA believes that now is the time to build upon the ACA to cover more of the uninsured. We look forward to being at the table to represent physicians and our patients to ensure that our patients are able to secure affordable and meaningful coverage, and access the care that they need.” Bailey said.