The Republican drive to repeal the Patient Protection and Affordable Care Act nearly got a surprise boost earlier this month from the American Medical Association, which up to now has provided valuable support for President Obama’s health care reform effort.

At the AMA’s interim meeting on Nov. 9, conservatives within AMA’s House of Delegates won a close vote to rescind the organization’s support for requiring all Americans to obtain health insurance, a key part of the new reform law. But, following desperate scrambling by AMA leaders, the House, in a second vote, narrowly decided to refer the issue to the AMA Board of Trustees and defer the issue until the annual meeting next June.

Conservative doctors, who have formed a Tea Party-type movement they call “Take Back the Profession,” vow to continue their fight to reverse AMA support for the individual mandate and emphasize the AMA’s more market-oriented policy positions. These include high-risk pools, insurance subsidies, and health savings accounts. And they want to make it the AMA’s top legislative priority to allow doctors to charge Medicare patients fees over and above what Medicare pays.

“I personally believe in a free republic, and it’s inappropriate to mandate the purchase of anything,” said Dr. Robert Sewell, a Texas surgeon who is immediate past president of the American Society of General Surgeons, which co-sponsored the resolution to revoke support for the individual mandate. “The AMA doesn’t have any business in this arena of how the government enforces its policies on people.”

But AMA spokesman Robert Mills said the organization “continues to support the individual mandate and delegates will continue to refine policy at future meetings to improve access and coverage.” No AMA leaders were made available for an interview.

Delegates who want the AMA to maintain its support for the individual mandate worry about the conservative push but hope the majority of delegates realize that the Affordable Care Act’s insurance market reforms, including guaranteed issue and a ban on pre-existing condition exclusions –which AMA policy supports — depend on requiring all Americans to obtain coverage.

“Without a mandate and universal coverage, insurers won’t eliminate the bad things we want to get rid of,” said Dr. Mario Motta, a cardiologist who is immediate past president of the Massachusetts Medical Society. “But opponents don’t have an alternative model. They are hung up on individual liberty. It’s ludicrous.”

The AMA And Health Reform: A Conflicted History

The intense maneuvering over the mandate at the AMA’s meeting in San Diego reflects the physician organization’s conflicted history with health care reform and universal coverage. Despite opposition from more conservative doctors, the AMA last November endorsed the health reform bill in the U.S. House of Representatives, at a key time when the Democrats needed help to pass reform. The AMA subsequently supported the Senate reform bill as well. At its interim meeting in November 2009, the AMA restated its support for the individual mandate.

The AMA’s position in this round of health reform contrasts with its more ambivalent posture during the battle over President Clinton’s reform plan in 1993-94.  At that time, a divided AMA torturously adopted a policy mostly backing the Clinton plan and the requirement that employers provide coverage to their workers. But after the AMA issued a joint statement of support with the AFL-CIO and AARP in the summer of 1994, it faced a fierce backlash from AMA conservatives and congressional Republicans. When Republicans took control of Congress in the 1994 election, the AMA retreated from its support for Clinton’s reform plan.

Before that, the AMA had a long history of rejecting government-led health care programs. It famously opposed the creation of Medicare in 1965, as well as prior efforts by Presidents Franklin Delano Roosevelt and Harry Truman to establish national health care programs.

This history is at least partly why it was politically dramatic and helpful to President Obama and congressional Democrats when the AMA backed their health reform proposals. “Given that there are other industries that are more powerful today in Washington, I don’t know whether it would have made a huge difference if the AMA had been on the other side,” said Jacob Hacker, a Yale University political science professor who is an authority on the politics of health reform. “But it certainly helped. And given the close vote [in Congress], everything that helped may have been decisive.”

Yet the battle within the AMA clearly isn’t over. At the organization’s interim meeting this month, the delegations from Kansas, Alabama, the District of Columbia, Florida, Georgia, and the American Society of General Surgeons offered a resolution to rescind support for the individual mandate and instead back tax incentives and non-compulsory measures to expand coverage. AMA committee leaders rejected that, arguing that eliminating the mandate would unravel insurance market reform and defeat the goals of expanding coverage and keeping premiums down. Committee leaders came back with a statement of the need to toughen the financial penalties for enforcing the mandate.

Angry conservative delegates flooded the microphones to testify in favor of amending the policy to revoke support for the mandate, and demanded a quick vote. The amendment passed by about a 52-48 percent margin. Then delegates had to vote on the full AMA reform policy, including that amendment. Mandate defenders led by Motta argued that the amendment would cut the heart out of AMA policy and should be reviewed by the AMA board and the Council on Medical Service. The House then voted by a similar margin to refer the entire policy to the Board for further study.

The Uncertain Road Ahead

“I was worried,” said Dr. David Downs, an internist with Kaiser Permanente in Denver who is an alternate delegate for the Colorado Medical Society. “A lot of people don’t grasp that without single payer, if you want to use markets, you need the individual mandate. But there’s clearly a contingent within the AMA House that doesn’t like mandates in principle and is trying to get them out of policy. I can’t tell you who’s going to prevail next June.”

Sewell hopes that by the time the AMA House again considers the issue, Republicans in Congress will have weakened or repealed the mandate. “I heard the argument that without the mandates the entire health reform law falls apart,” he said. “If it falls apart, so be it. We as a society have been duped into believing there’s something fundamentally wrong with the American health care system. I don’t see anyone lying around on the street dying. Everyone is getting health care.”

Others expect a push by conservative delegates to reverse AMA policy by electing doctors who oppose the reform law to AMA board and key council positions. That’s what happened at the AMA in the 1994-1995 period, when top staffers supportive of the Clinton plan also were pushed out; some AMA leaders at the time complained that congressional Republicans spearheaded that effort, as part of what became known as the GOP’s reverse lobbying campaign. Last June, however, AMA conservatives tried but mostly failed to elect anti-reform board and council members.

Hacker says it’s possible that newly empowered congressional Republicans will try to install anti-reform leaders at the AMA. But he believes it’s less likely they would focus their reverse lobbying efforts on the AMA this time because the doctors’ group has lost membership and power in relation to other health care lobbies, such as the hospital, pharmaceutical, and insurance industries. “If Republicans are thinking of reverse lobbying, there are a lot of potential targets,” he said.

Motta predicts AMA leaders will stick with the policy of expanding health coverage through the individual mandate, but it will be rocky. “They are in an unenviable position of having to bridge some very divergent views,” he said.