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CHICAGO -- Naturopaths, homeopaths, and other alternative medicine providers are allowed to write vaccine exemptions in some states, a "loophole" that some American Medical Association (AMA) delegates adamantly say their organization should work to close.

"Although exemption [rules] vary from state to state, all immunization laws grant [vaccine] exemptions for medical reasons," said Aparna Kanjhlia, on behalf of the Medical Student Section, which proposed the policy change. "However, some states have a broad definition" of who can provide those exemptions.

"This resolution would provide additional support for the AMA to oppose state-level activity that gives non-sufficient providers, including alternative practitioners, the latitude" to grant medical vaccine exemptions, said Kanjhlia.

She made her remarks during a reference committee session Saturday during the AMA's of the House of Delegates, where dozens of resolutions were under consideration for potential votes before the full House of Delegates on Monday and Tuesday.

Ray Callas, MD, of the Texas Medical Association, called the states' permissiveness "a scope of practice creep," in which non-medically trained individuals assume they can provide services properly provided by physicians. He said that failing to close such a loophole could be dangerous, allowing people to practice medicine "without going to medical school."

Added Christopher Gribbin, MD, a delegate from the Medical Society of New Jersey: "This is a scope [of practice] issue. There are lots of mid- and lower-level providers who want to do our jobs for us. And this is certainly one way for them to get into the business, and something we need to oppose."

Gribbin noted "a whole cottage industry that has sprung up on granting and giving individuals the 'background' to apply for an exemption," and websites where you can obtain appropriate clearances to present to your employer for an exemption.

Jose Mitjavila, MD, an Indiana delegate, said he was disconcerted by the news that unlicensed, non-medically trained providers can legally exempt people from vaccine requirements.

They "are actively subverting our efforts by granting vaccine exemptions to patients that do not necessarily need these vaccine exemptions without even any medical basis, and quite frankly, just misinforming patients," he said. "The importance of vaccination against COVID-19 has been overwhelmingly demonstrated."

Not everyone agreed that only physicians should be legally able to write medical exemptions for immunizations, however.

"Our focus should be on the science, and of making sure that all healthcare professionals -- non-physicians and physicians alike -- adhere to that," said Peter Hollmann, MD, a delegate from Rhode Island.

He may have been referring to a number of clinicians around the country who have gotten in trouble with their state medical boards for signing COVID and other vaccination exemptions for patients without proper documentation or necessity, or for a certain fee.

Marianne Parshley, MD, a delegate from the American College of Physicians, from Oregon, said that with patient-centered medical homes that use interprofessional care-team models, such as the one she works with, nurse practitioners and physician assistants "also are allowed to designate whether someone gets a medical exemption."

"I really don't think ... that in primary care, we should be loading all of the responsibility of designating someone as being medically exempt for vaccinations onto the physicians. We need to do team-based care," Parshley said.

"On the other hand," she added, "in our area, the naturopaths and some chiropractors have been the ones who have been lining patients up and giving them religious and non-religious exemptions."

Deciding which patients might have medical conditions serious enough that the vaccine might pose greater risk of illness than the disease is not easy, said Michael Butera, MD, a California delegate representing the Infectious Diseases Society of America.

"These nuances require critical thinking and decision-making" and is in the purview of physicians, or physician-guided or physician-directed nurse practitioners or physician assistants, Butera said.

Another issue that found disagreement among delegates was one that would authorize the AMA to support federal minimum wage regulation. The index would rise with inflation "in order to prevent full-time workers from experiencing the adverse health effects of poverty," according to the proposed resolution.

"We're not a bunch of economists, so we shouldn't be directly involved in determining the exact level," said Ryan Englander, a Connecticut delegate representing the Medical Student Section that proposed the resolution. But, Congress too often fails to consider health benefits of raising the wage, such as decreases in mortality from cardiovascular disease, HIV infection, suicide, and infant mortality, he noted.

Marilyn Heine, MD, of the Pennsylvania Medical Society, pointed out that the federal minimum wage has been set at $7.25 per hour since 2009. "Yet," she argued, "the average yearly inflation has increased steadily during that time due to long-standing systemic and structural discrimination."

Some members bridled at that, saying that since costs of living vary from state to state, the matter should be left to the states or individualized.

Jason Goldman, MD, a delegate from the Florida Medical Association, who is in private practice, opposed the resolution, saying it is increasingly difficult for him to hire and pay his staff because of insurance company and federal payment cuts "that directly impact our ability to keep our doors open."

Wages should be "handled at a local and state level and not dictated by an arbitrary federal wage standard."

Also opposed was Jordan Warchol, MD, a delegate from the Nebraska Medical Association. He wanted the issue moved to referral for more study because of its complexity and variation in costs from state to state. "Just today, friends were discussing what it takes to buy a house in Nebraska versus what it takes to buy a house in the Bay Area."

Another issue that brought dozens of speakers to the forum for more than 30 minutes was the "Period Poverty" resolution, which would prompt the AMA to advocate that "feminine hygiene products" such as tampons, pads, and diapers be considered medical necessities and qualify for coverage in appropriate public assistance programs. That's because so many people can't afford to buy them, and suffer adverse physical and mental health consequences, as well as absenteeism from school.

It also would have the AMA "encourage public and private institutions as well as places of work and education to provide free, readily available menstrual care products to workers, patrons, and students," according to the proposal.

If it passes, this resolution would empower the AMA to encourage the Occupational Safety and Health Administration (OSHA) and other entities to establish a practice standard for employers to offer the products for free.

"Studies have shown that period poverty impacts the school performance of one in five school-age girls, and roughly three out of four working women has left work early" to obtain these products, said Medical Student Section delegate Yunghang Chan, of the New York Medical Society.

Half of the low-income women in major U.S. cities "have to choose between food or menstrual hygiene products" and use unsafe alternatives "despite the higher risk of severe complications such as infection or even toxic shock syndrome," said Chan.

However, James Milam, MD, an Illinois Medical Society delegate, took issue with the resolution's use of the word "free."

"I don't think we should be asking OSHA to enforce a standard of practice for free menstrual care products, and I don't think we should be telling the public and private sector folks what they should pay for for their employees," he said. "As we all know, there's no such thing as a free lunch."

The AMA delegates in the committee grouped four similar resolutions seeking to put off or thwart looming federal and private insurance physician fee schedule payment reductions that will reduce fees to some practices by 9.75%, when "practices have not yet recovered from the financial strain of the COVID-19 pandemic," the proposal reads.

Heatedly discussed was the issue of budget neutrality, in which annual Medicare fee increases or decreases applicable to CPT codes used by various specialty or primary care practitioners must by definition balance each other out. A relief package from some of the cuts that took effect for 2021 will expire at the start of 2022.

Gribbin spoke again for the New Jersey delegation saying that budget neutrality must go. "One of the consequences of budget neutrality is it pits us against each other," he said. "For every gain that a proceduralist makes, it may be a loss for a cognitive physician and vice versa. And this of course plays into the hands of the payers, and keeps us at each other's throats."

The Reference Committee will make a recommendation on passage or rejection of these items at Monday or Tuesday's House of Delegates session.

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