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Final Response to Letters Regarding the EMBRACE Healthcare Reform Plan
Submit responseEMBRACE was developed as a blend of what is needed and what is feasible in healthcare reform, but due to space constraints many details of the plan were omitted.*
It is not a plan based on opposition to single-payer proposals; rather, it is a plan that shares the goals of a single payer system, but seeks to achieve these objectives in a form apt to be more tenable in the context of US politics and American values, and might even offer operational advantages. The inclusion of private, for profit health insurance carriers in EMBRACE is not only pragmatic, but also follows the example of most of the successful single payer systems in Europe and Canada. In those systems, private insurance has developed “after-the-fact” but there has been an effort to integrate it into the publicly financed system, often with great difficulty. By designing EMBRACE around a multi- tiered system from the start, it allows this integration to occur more effectively. The notion that you can get more by paying more is simply part of the American psyche; the American attitude toward healthcare. EMBRACE, in essence, embraces health care as both a right and a privilege, using a multidisciplinary board of experts to draw the line between the two.
We agree that much of the dysfunction of the existing healthcare system is related to the enormous profit and overhead associated with private insurance (Young) but take exception to the suggestion that Tier 1 would exclude “all medically necessary care, including long-term and dental care, with no co-pays or deductibles.” The opposite is evident: If the Board decides that certain services are life saving, life extending or preventive, they would be available universally in EMBRACE through Tier 1. We also disagree that EMBRACE “would continue to deny us the vast administrative savings achievable only under a single-payer plan.” Through the use of the web based universal billing system, almost all administrative overhead for physician offices and hospitals would be eliminated.
In regard to rationing (O’Brien and Frey), it must be said that all health care systems ration care; no country is able to afford covering all services for everyone. In our current system this rationing occurs irrationally, based on income, state of employment, pre-existing conditions and age. In countries with single payer systems the rationing is more rational and often depends on evidence-based data; but since there is always a limit on funding for these systems, there are always uncovered services and they effectively become multi-tiered. EMBRACE acknowledges this and incorporates the tiers in one cohesive system. In other words, the proposal accepts that rationing at some level is unavoidable, and thus approaches it methodically and rationally. The multidisciplinary Board proposed in EMBRACE is specifically conceived to oversee this issue, and ensure that the availability of services conforms to the prevailing priorities and values of our society.
For the healthcare system as a whole, it is important for the Board to be able to tailor Tier 2 plans to complement but not duplicate Tier 1 services. It is also important for the Board to be able to change Tier 2 plans as more evidence-based data become available and services are moved from Tier to Tier. The Board might decide to create plans that are specific to certain patient populations (such as the poor, the elderly, physical laborers, etc.) and even purchase or at least subsidize Tier 2 coverage for what now are Medicaid patients (or these could be purchased by individual states). In addition, we believe that Tier 2 plans will be significantly cheaper than private plans are in our current system so that it would be easier for small businesses, government (federal, state or local) and especially individuals to afford such coverage. With some public supplementation, we believe that we could reach near universal Tier 2 coverage.
The menu system with a limited number of plans (Johnson) creates a fully portable Tier 2 and allows the consumer to be able to compare prices between insurance companies in a way that the current system (or a system that allows insurance companies to develop their own plans) does not allow. This will be particularly important in a system that moves away from employer-based insurance coverage as is the case with EMBRACE.
Regarding the concerns raised by Dr. Gibson, EMBRACE would allow physicians to work independently in compliance with the guidelines on the World Medical Association International Code of Medical Ethics web site. However, as noted above, there could be situations in which the Board would subsidize some plans in Tier 2.
As for allowing the U.S. government to initiate and maintain a national medical information bank accessible by doctors at the point of care as part of Tier 1 health care, we fully agree. In fact, we envision this data bank encompassing all three tiers in the EMBRACE system.
Finally, we are at a critical juncture in the debate on healthcare reform and this opportunity should not be missed by failure to find a way to make what is necessary for all, acceptable to a majority- and thus, achievable.
*For a more detailed description of the EMBRACE plan please visit www.hpfhr.org
Conflict of Interest:
None declared
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Tiered health insurance plan fatally flawed
Submit responseDear editor,
Re “The Expanding Medical and Behavioral Resources with Access to Care for Everyone Health Plan” (April 7):
While the objectives of universal coverage, reducing administrative costs, and building on the public financing of health care are laudable, the proposal of Lancaster, et al., for a three-tiered health insurance system is fatally flawed.
By dividing the population’s health coverage into tiers, a major share of which is to be financed by for-profit, private insurers, the Lancaster proposal would perpetuate the wasteful fragmentation of our dysfunctional system. Such multi-payer inefficiency would continue to deny us the vast administrative savings achievable only under a single-payer plan.
The proposal’s vague language differentiating the basic, publicly financed level of care (Tier 1, covering therapies regarded as “life-saving, life-sustaining, or preventive”) from the optional, privately financed Tier 2 coverage (covering “all therapies considered to help with the quality of life”) would invite frequent quarrels over claims. Insurance companies would exploit such ambiguities to evade payment and shift costs to patients and the government.
Such an arrangement would also perpetuate disparities in access to care. Some patients would be unable to afford Tier 2 insurance. Others might end up buying skimpy coverage, leaving them vulnerable to financial hardship when illness strikes.
If, under the Lancaster proposal, Tier 1 covered all medically necessary care, including long-term and dental care, with no co-pays or deductibles, it would be comparable in terms of patient benefits to those offered by a single-payer system. But Tier 1 offers no such thing.
Nor, for that matter, does the overall proposal provide the strong cost-control and health planning advantages of single payer.
Why do the authors feel obliged to offer their alternative? It boils down to the familiar “feasibility argument.” The authors write, “A system that continues to allow private, for-profit insurance and some degree of free market forces would be more viable than a system that attempted to control or eliminate them.”
This conclusion reflects, more than anything else, the power of the private health insurance industry to dictate the acceptable parameters of discourse.
Single-payer systems are not only viable (Medicare being but one example), they enjoy solid majority support among the public. And one yearago the Annals published a study showing 59 percent of physicians now support government action to establish national health insurance.
We should implement single-payer health reform without delay.
Conflict of Interest:
None declared
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Re: Tier 2 Clarification
Submit responseIn response to Johnson:
EMBRACE strives to accomplish transparency, uniformity and portability in Tier 2.
In the current system, most insurance is obtained through one’s employer who often negotiates with an insurance company for specific features and pricing. In many cases these plans are unique to the particular place of employment. This means that if the employee decides or needs to change jobs, they may not be able to keep the same plan. Apart from the inconvenience, these changes in plans often mean that the consumer must find a different healthcare provider (from a panel of approved providers) and even different approved medications.
If an individual consumer wants to purchase healthcare insurance on his/her own, the task is even more daunting. First, most consumers do not have the knowledge or expertise to understand the content of insurance plans (in fact, this is probably true of most small business owners as well). Often they may rely on the insurance agent to suggest various features and may not fully understand what they are purchasing. They also may not be aware of items that are missing from the plan that may leave the consumer uncovered for important services or events. In addition, the individual consumer has no negotiating power to get better terms or pricing in the contract they buy.
This is exemplified by our experience with Medicare D where the consumer was faced with a confusing and hard to understand list of choices for drug coverage. With dozens of unique plans designed by the insurance and pharmaceutical industry, there was tremendous confusion and very little possibility to compare plans. Having each insurance company offer the same benefits would avoid that step and would benefit the consumer of healthcare.
The menu system allows the consumer to be able to compare prices between insurance companies in a way that the current system (or a system that allows insurance companies to develop their own plans) does not allow. This will be particularly important in a system that moves away from employer-based insurance coverage as is the case with EMBRACE.
Finally, for the healthcare system as a whole, it is important for the Board to be able to tailor Tier 2 plans to complement but not duplicate Tier 1 services. In addition, it is important for the Board to be able to change Tier 2 plans as more evidence-based data become available and services are moved from Tier to Tier.
Conflict of Interest:
None declared
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Tier 2 Clarification
Submit responseThank you for this lucid and coherent alternative health care proposal. After studying the Oregon rationing experiment and the current system as well as single-payer alternatives, I had come to the conclusion a multitiered system made the most sense. Now I have a specific plan to embrace. We should cover basic care for everyone, but we cannot cover all care for all people all the time. Rationing "rationally," while leaving in place market forces to encourage dynamism and progress in new therapies combines the best of both models. One could argue that we already have a three-tiered system currently, except that Tier One consists of emergency room visits (and sometimes subsequent admissions) only.
My main question is on Tier 2. Why under the EMBRACE plan do these insurance policies only inlude a "limited number of plans that would be developed by an oversight board?" Why would the Board be responsible for crafting specific plans and then requiring insurance companies to cover those specific conditions? Why not allow the private insurance companies to develop and price these plans? I understand the advantage of a central billing system for administrative reasons, but I don't understand why central planning is necessary to distinguish between what is covered as Tier 2 vs Tier 3, and what combinations of plans would be offered for Tier 2.
Conflict of Interest:
None declared
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Responses to Comments
Submit responseIn response to O’Brien and Frey:
First we must state that we cannot predict what the Board will decide in regard to absolute criteria for tier placement. Since the Board will be composed of physicians, other healthcare professionals, public health experts and healthcare economists, criteria for tier placement will undoubtedly involve many different factors, including the socio-economic and even the moral impact of specific coverage. In fact one of the major advantages of the Board will be to make the difficult moral, ethical and economic decisions (such as end of life care) that cannot be made in the present system.
In regard to rationing, it must be said that all health care systems ration care. This is because no country is able to afford covering everyone for all services. In the current system in the U.S., this rationing occurs irrationally, based on income, state of employment and age. In countries with single payer systems the rationing is more rational and often depends on evidence-based data; but since there are always uncovered services these systems effectively become multi-tiered systems. EMBRACE acknowledges this and incorporates the tiers in one cohesive system.
Another advantage with EMBRACE is that because Tier 2 is part of the system there are many ways to use it to enhance Tier 1. The Board may decide to create plans that are specific to certain patient populations (such as the poor, the elderly, physical laborers, etc.) and even purchase or at least subsidize Tier 2 coverage for what now are Medicaid patients. In addition, we believe that Tier 2 plans will be significantly cheaper than private plans are in our current system so that it would be easier for small businesses, government and even individuals to afford.
In regard to the specific patient with rheumatoid arthritis, it is very likely that the Board may decide that early intervention in RA is worth investing Tier 1 resources on proven therapies to prevent later complications. This also applies to patients with developmental disabilities, especially those who are at increased risk for infections or other complications.
In Response to Gibson:
Point 1: The ethical duties of doctors shall not be infringed.
Response: EMBRACE allows physicians to work independently in compliance with the guidelines stated in World Medical Association International Code of Medical Ethics web site.
Point 2: No taxpayer monies, nor government funds shall subsidize private (Tier II or Tier III) health care.
Response: Although this is generally true in EMBRACE, there may be some instances where the Board may purchase or subsidize some plans in Tier 2 (see above).
Point 3: The U.S. government should initiate and maintain a national medical information bank accessible by doctors at the point of care as part of Tier I health care.
Response: We agree. In fact, we envisage this data bank encompassing all three tiers. This, we believe, will be helpful to analyze utilization, effectiveness and outcomes. This feature will be unique to EMBRACE since almost all medical, psychiatric, surgical, obstetrical and even chiropractic services will be “on file”.
Point 4: At least 90% of all money paid in medical liability expenses in the United States should go to injured parties.
Response: EMBRACE does not cover this issue.
Point 5: Wasteful and corrupt profiteering that infringes upon the rights of patients and doctors should be exposed and eliminated.
Response: We agree.
Conflict of Interest:
None declared
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Re: EMBRACE Health Plan
Submit responseWhat Tier would persons with chronic, debilitating but not life threatening diseases fit into? Consider persons with rheumatoid arthritis or those with developmental disabilities who also have mental illness. These are clearly questions of “quality of life” and maintenance of function.
It therefore seems that they would fall into Tier 2. If so, and those with such conditions cannot afford private insurance premiums, will they simply suffer the “functional impairment,” the pain and disability? Will they qualify for Tier 1 only after their condition deteriorates to the point that it is life threatening?
This perpetuates rationing by income, rationing for the poor but not others. And it could actually increase overall expenses as non-covered chronic conditions deteriorate.
It is possible that the “Board” could consider the “economic effects” that such “functional impairment” might have on the society and conclude that such conditions should be covered because they improve economic productivity and include them in Tier 1. But if persons so afflicted are not economically productive or their economic productivity declines, will they then fall in Tier 2? If so, this constitutes allocation of resources on the relative worth of individuals.
Do we really want to make choices on the basis of differences of individual worth? Is it moral?
Will insurers in Tier 2 be allowed to risk-rate premiums or deny coverage to persons whose chronic diseases are likely to be especially expensive to treat? If so, Tier 2 coverage will again be subject to rationing by income and wealth, either because many will be unable to afford high risk-adjusted premiums, or are denied coverage and can’t afford the out-of-pocket costs of care.
Given the disparities of income and wealth in the U.S., this seems to us a continuation of America’s current policy of rationing care based on income and wealth.
This proposal, presented in such general terms, carries great risk of perpetuating or even expanding injustice in our health care. As such, it is not supportable.
Conflict of Interest:
None declared
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Health Care Reform
Submit responseDear Colleagues,
This ACP proposal is a good start in returning CARE to U.S. Health care. Five elements should be addressed:
1) The ethical duties of doctors shall not be infringed (http://www.wma.net/e/policy/c8.htm).
2) No taxpayer monies, nor government funds shall subsidize private (Tier II or Tier III) health care.
3) The U.S. government should initiate and maintain a national medical information bank accessible by doctors at the point of care as part of Tier I health care.
4) At least 90% of all money paid in medical liability expenses in the United States should go to injured parties.
5) Wasteful and corrupt profiteering that infringes upon the rights of patients and doctors should be exposed and eliminated (www.garyrgibson.com).
Conflict of Interest:
None declared