CHICAGO -- The American Medical Association's House of Delegates has reaffirmed its support of individual responsibility -- including a requirement that most U.S. residents buy health insurance -- as the foundation of universal coverage.

"The AMA has a strong policy in support of covering the uninsured, and we have renewed our commitment to achieving this through individual responsibility for health insurance, with assistance for those who need it," said AMA President Cecil Wilson, MD.

The issue emerged at the AMA's 2011 House of Delegates meeting as a lightning rod in nation's largest doctors' organization, which spent Sunday debating the issue and on Monday voted 326 to 165 to reaffirm the AMA's policy on "individual responsibility," as the organization calls it.

AMA's current "individual responsibility" position supports requiring individuals and families earning more than 500% of the federal poverty level to obtain, at a minimum, catastrophic health insurance coverage and coverage that pays for preventive healthcare. The policy endorses using the tax structure to get people to comply.

The AMA does not use the term "mandate" in its policy position, but it is difficult to interpret the vote in the House of Delegates as anything other than support for an individual mandate.

Under the Affordable Care Act (ACA), nearly every U.S. citizen will be required to have health insurance starting in 2014 or else pay a penalty. The federal law requires that people have insurance plans that meet a minimum benchmark, which is higher than just covering catastrophic care and preventive services.

The AMA did not adopt another resolution -- introduced by several Southern doctors' delegations and American Academy of Facial Plastic and Reconstructive Surgery, the American Association of Neurological Surgeons, and the American Society of General Surgeons -- that would have rescinded the AMA's old policy and replaced it with one that encourages the purchase of health insurance by "tax incentives and other non-compulsory measures," but does not require it.

Although the AMA's individual responsibility policy has been on the books for five years, it's not surprising that the issue is creating major contention now within the AMA: The group's support of the healthcare reform law sharply divided the organization and is often cited as the most likely explanation for a precipitous decline in membership.

AMA's leadership denies the group's support of the ACA has led to a drop in membership, but the group's membership has continued to decline since the law passed in 2010, and 12,000 doctors quit in the past year.

The AMA's Medical Services Committee spent three hours on Sunday engrossed in heated debate over the individual mandate, with those who oppose a mandate saying that requiring everyone to purchase insurance is unconstitutional and unnecessary, and a major over-reach of the federal government.

The issue is currently playing out in the courts, and the Supreme Court will likely be the final arbiter of the constitutionally of the individual mandate.

Those in favor of the mandate and the AMA's current stance argued that without the requirement to have health insurance, many people would not purchase it, and if they had to get medical treatment, the costs would be passed to others.

In the courts, supporters of the mandate argue that it's the linchpin of the ACA and the law would fall apart without it.

Wilson said the AMA has reviewed other options, but determined that without "individual responsibility for health insurance" a healthcare reform approach "cannot be fully successful in covering the uninsured."

AMA members and delegates who oppose the mandate said it conflicts with AMA's policy in support of freedom of choice, pluralism, free-market economic principles, and preserving the physician-patient relationship.

But others said that mandating insurance coverage will drive many to buy plans from private insurance companies (unless they qualify for Medicaid or Medicare), which does support the AMA's endorsement of free-market competition in healthcare.