Comments and Critiques on the EMBRACE Health Care Reform Plan

IN RESPONSE:

The Expanding Medical and Behavioral Resources with Access to Care for Everyone (EMBRACE) plan was developed as a blend of what is needed and what is feasible in health care reform, but because of space constraints, many details of the plan were omitted. For more details, readers can visit www.hpfhr.org.

EMBRACE is not based on opposition to single-payer proposals; rather, it shares the goals of a single-payer system but seeks to achieve those goals in a form more likely to be tenable in the context of U.S. politics and values and that 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 efforts have been made to integrate it into the publicly financed system, often with great difficulty. By designing EMBRACE around a multitiered system from the start, this integration can occur more effectively. The idea that you can get more by paying more is part of the U.S. psyche and attitude toward health care. EMBRACE, in essence, embraces health care as both a right and a privilege and uses a multidisciplinary board of experts to draw the line between the 2.

We agree with Dr. Young that much of the dysfunction of the existing health care system is related to the enormous profit and overhead associated with private insurance but take exception to the suggestion that Tier 1 would exclude “all medically necessary care, including long-term and dental care, with no co-payments or deductibles.” The opposite is evident: If the board decides that certain services are life-saving, life-extending, or preventive, those services 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.” Use of the Web-based universal billing system would eliminate almost all administrative overhead for physician offices and hospitals.

In regard to Drs. O'Brien and Frey's comments, all health care systems ration care; no country can afford to cover all services for everyone. In our current system, this rationing occurs irrationally, on the basis of income, employment, preexisting conditions, and age. In countries with single-payer systems, the rationing is more rational and often depends on evidence-based data. Because these systems always have a limit on funding, not every service can be covered. This effectively makes all systems multitiered. EMBRACE acknowledges this and incorporates the tiers in 1 cohesive system. In other words, our 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 to ensure that the availability of services conforms to the prevailing priorities and values of our society.

For the health care 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 create plans that are specific to certain populations (such as poor persons, elderly persons, or physical laborers) and even purchase or at least subsidize Tier 2 coverage for persons who are now on Medicaid (or coverage could be purchased by individual states). In addition, we believe that Tier 2 plans will be substantially cheaper than private plans in our current system; therefore, 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 near-universal Tier 2 coverage is possible.

In response to Dr. Johnson, the menu system with a limited number of plans creates a fully portable Tier 2 and allows the consumer 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. This will be particularly important in such a system as EMBRACE that moves away from employer-based insurance coverage.

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 previously, situations could occur 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 physicians at the point of care as part of Tier 1 health care, we fully agree. In fact, we envision this data bank encompassing all 3 tiers in the EMBRACE system.

We are at a critical juncture in the debate on health care reform, and we should not miss this opportunity by failing to make what is necessary for all acceptable to a majority.