The American Medical Association (AMA) — one of the nation’s most powerful health groups — is warming up to policy ideas that expand the role of government-run health care, thanks to activists trying to change minds from the inside.  

Every year, the country’s largest physician group hosts a meeting to discuss its priorities. The top-line from this year’s annual conference is that the organization will continue its support for the Affordable Care Act (ACA) while still opposing single-payer health care. “The ACA should be strengthened, not abandoned,” said the AMA, summarizing the conference on its website.

But on Tuesday, the AMA nevertheless came close to eliminating its decades-long position against single payer, or a system where everyone gets health care through one insurer run by the federal government. A day before, the AMA agreed to study public option approaches, where the federal government would expand access to existing public plans while leaving private plans alone. The growing support within AMA to at least neutralize its long-held position on the matter presents something of an internal tension, as the group is part of a coalition of organizations which are actively lobbying against these kinds of policies.

The AMA did not respond for comment.

The House of Delegates, the policy-making body within the more than 200,000 member organization, rejected a resolution introduced by the AMA’s own student caucus to put an end to its current stance on single payer. Many dismissed the vote as just another rebuke to Medicare for All, but it was the closest single-payer activists ever came to changing AMA’s position; the vote was 292 to 254, or 53% to 47%. Activists intend to try again.

“This vote means that we are moving in the right direction,” said Alankrita Siddula, a third-year medical student at Rush University. She’s a member of both the AMA Medical Student Section and Students for a National Health Program.

“We are doing all this hard work and it’s not for nothing — we are changing minds. And hopefully, at the next meeting, maybe something can happen,” she added. 

While these intra-organizational wranglings can all seem very “inside baseball,” the AMA plays a critical role in the larger debate over health care reform, and the way in which the organization evolves on these issues has the potential to radiate beyond its closed doors. For instance, the AMA has a lot of pull on Capitol Hill, where they spent about $1 million on the campaigns of congressional candidates during the last election cycle. 

Given its influence, single-payer activists have been trying to change its mind for years. There have been some signs suggesting that change is beginning to manifest. For example, the The Journal of the American Medical Association (JAMA) published its first positive opinion piece on single payer in more than 15 years. 

The Medical Student Section’s behind-the-scenes efforts began five years ago, when the caucus initially embraced single payer. The students then forced the AMA during its 2018 meeting to neutralize its public stance. Instead of doing so, the House of Delegates agreed to study single payer. 

“To us, it doesn’t seem as genuine to continually say they are open to discussing it when they hold policy that is explicitly against it,” said Siddula, “They can’t be coming to the table open about it when they already made up their minds.”

The current policy also gives the AMA the liberty to lobby against single payer. Indeed, the AMA is a part of the Partnership for America’s Health Care Future, a coalition of influential industry groups that formed just to defeat policies like single payer or public option proposals.

“So as the [AMA Medical Student Section] supports single payer, our membership dues go toward lobbying against single payer. It seems disingenuous to us,” Siddula told ThinkProgress. The Medical Student Section is also the largest section of the AMA, she added.  

Siddula, who never had continuous health care coverage growing up, personally knows what it’s like to be without health insurance. She also lacked insurance when she got hit by a car after just graduating college. At the time, she even refused the ambulance when it showed up to transport her to the hospital, out of concern that she’d have less money on hand to make her student loan payment. That’s why she — along with several hundreds of doctors, nurses, and medical students — rallied outside AMA’s annual meeting over the weekend to get it to cease its opposition to single payer.   

“It was a terrifying time, not because I had blown my knee, needed surgery, therapy, and could face lifelong complication from this, but I felt worthless for being unable to afford care,” she said, “Now, in looking back it is incredulous to me that I and hundred of other Americans face this issue daily, choosing between cost and life. But that is the reality of our system, putting profits over lives means only those with privilege can live.”

There’s still a lot of work ahead of Siddula and the other AMA student members. Citing a variety of concerns with single payer, the Council on Medical Service recommended the AMA endorse strengthening the Affordable Care Act by making more people eligible for subsidized private plans. Historically, the House of Delegates makes its decisions principally on the recommendations developed by this council. 

“[F]ocusing the efforts of our AMA on improving the ACA helps promote physician practice viability by maintaining the variety in the potential payer mix for physician practices,” the council said in the evaluation. “Importantly, the Council is concerned about the cost of proposed Medicare-for-All proposals, and how the proposals’ pay-fors would impact patients and physicians.”

Just as they agreed to study single payer, the House of Delegates voted to study public option proposals. But the body didn’t go as far as the American College of Physicians (ACP) had hoped.

“We supported most of the recommendations on closing coverage gaps in the Affordable Care Act, but we wanted the AMA to go beyond that by supporting public options,” said Bob Doherty, ACP’s senior vice president of governmental affairs and public policy.

The ACP isn’t looking for the AMA to endorse a specific idea — be it a Medicare buy-in, Medicaid buy-in, or the Center for American Progress’ plan. (Editor’s Note: ThinkProgress is an editorially independent newsroom housed at the Center for American Progress Action Fund.) The ACP offered a resolution for the AMA to declare support for public option proposals more broadly in part so that they won’t be opposing them, said Doherty. By being a part of the Partnership for America’s Health Care Future, AMA is actually working against bills aiming to implement some kind of public option. 

“It’s a little bit ambiguous,” Doherty told ThinkProgress, “I think it leaves it up to the AMA leadership and staff to evaluate — read the tea leaves in terms of what the House of Delegates wants and how that might affect their advocacy.”

There’s a possibility the AMA announces support for a public option approach. “While the Council continues to believe that AMA should not support single-payer proposals, there is the potential for other health reform proposals to be put forward in the future that could be consistent with AMA policy,” the council said in its single-payer analysis.

Siddula doesn’t view the AMA studying public option proposals as working against her own efforts. In fact, an evaluation might show the inadequacy of such ideas as compared to single payer, she said.

Nevertheless, the conversations within AMA about single payer and public options bespeak a remarkable sea change. And that shift also appears to track with public sentiment. There’s a growing support among everyday people for Medicare for All. Public option approaches also poll well.

“The medical profession mirrors the broader public in many ways — frustrations with the current health care system,” said Doherty, “Frustrations with the administrative burden of dealing with so many insurers, each with their own rules and regulations; frustrations with coverage gaps; frustrations with narrow networks, high deductible plans and obviously frustrations with the cost of care.”