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Healthcare Professionals for Health Reform has proposed an alternate plan for reform called EMBRACE in the Annals of Internal Medicine:

The group proposes a tiered plan, the core of which (Tier 1) would be lifetime, basic, publicly funded coverage for the entire population on the basis of the best evidence about which therapies are considered life saving, life-sustaining, or preventive. Optional coverage (Tier 2) would be funded by private insurance and cover all therapies considered to help with quality of life and functional impairment. Items considered to be luxury or cosmetic (Tier 3) would generally not be covered, as is the case under the current system.
Should Congress consider EMBRACE as an alternative to the plans currently being discussed?  How would a tiered system compare with the current system and with the reform being discussed in Congress?

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  1. Selvoy M Fillerup


    A public plan option is not a totally new idea. Similar systems already function in Australia, Ireland and Germany. For years now, in each of these nations, citizens have been able opt-out of an already existing public plan and go to the private health insutrance market for coverage.

    The concern now is not that the public plans will drive the private insurance industries out of business, but that the service and efficiencies of the private plans have eclipsed the service in the public plans and still remain profitable.

  2. Gil Lancaster


    There are 6 main points regarding the current legislation in Congress and EMBRACE (

    1) Piecemeal healthcare legislation (separate insurance reform, health information technology development, medical guideline commissions etc.), which is what Congress is now considering, without clear oversight or objectives can only lead to an inefficient system (at best) or a system that conflicts with itself (and may ultimately fail).

    2) EMBRACE uses already existing (and tested) concepts and infrastructures to create a comprehensive reform that not only will be budget neutral, but will be sustainable and best of all will significantly improve the health of the country.

    3) EMBRACE essentially offers a "safety net" of coverage to the entire population, while preserving a robust insurance industry, keeps a user friendly system (for patient AND doctor) and provides a mechanism for developing an intra-operable medical records network (which can be developed like the apps on iphone are now).

    4) EMBRACE offers full portability (from job to job and state to state) and relieves all obligation for businesses to provide insurance. The latter will help with pension plans of big businesses (like GM) and the high expenses of small businesses. Yet, if business want to offer perks (such as higher level of insurance) they still can.

    In summary, EMBRACE can act as a guideline for legislation that will eventually give us a truly effective AND efficient healthcare system that will preserve all the good things that the American system has.

    5) EMBRACE offers comprehensive insurance market reform. Even the single payer system is not as comprehensive since it ignores the private insurance industry that will eventually still flourish and compete with the single payer system (leaching off the least risky to insure) as it has in almost all countries that have it. As for the "Public Plan" proposal that seems to be the most likely model for the insurance reform that Congress will pass, it is hardly "insurance market reform". All it will do is set up a Medicare-like plan available for ages 18-65 that is supposed to compete with the private plans. This will not only not regulate the insurance companies (its innovator, Jacob Hacker, believes that the competition will lead the private insurance companies to improve their service) it will fall victim to the innovation of the insurance industry to circumvent the competition (remember this a completely untested system) and probably doom it to failure. My fear is that this will set back healthcare reform AGAIN for another 15 years and maybe even longer. EMBRACE actually recreates many of the systems that now exist in Europe and even Canada (so there is some track record for this) with parallel but separate public/private insurance coverage, but EMBRACE does it from the ground up (rather than later modifying the system as it has in the other countries).

    6) EMBRACE addresses the needs of primary care physicians. By including, and having an emphasis on preventative care the system not only directs these services toward the primary care provider, it also recognizes many of the services that are not reimbursed now (such as smoking cessation and weight control counseling), and even has a system to update the medical evidence that physicians rely on. Like the "Medical Home" that the ACP advocates, this system will empower the primary care giver as the primary decision maker and will assure proper remuneration. EMBRACE, however, will also significantly reduce or even eliminate most of the overhead that physician offices have (from dealing with private insurance and privatized Medicare) and supply the practitioner with updated, reliable guidelines tailor-made for their practice. What reform can be better than not only being reimbursed for all you do AND not to have to hire anyone to do your billing!

    Finally, it seems that Congress has already made up its mind on minimal, piecemeal insurance reform (rather than healthcare reform). I only ask that in the meantime DFA members consider a back-up plan like EMBRACE for what looks like a long fight.

  3. Susan Mahoney


    One problem with our healthcare system is NOT lack of insurance, but the dysfunctional roles the insurance industry has taken up in our society: its stranglehold on our freedom to work where our interests and talents lie; interference with our private lives and personal information; interference with our doctors; denial of necessary healthcare; and then the constantly increasing premiums and distortion of labor costs that drag down our economy.

    The other significant element in our system is the very high costs of visits, procedures and medicine. Insurance is only one of the contributors to this problem.

    So, I agree that Congress is probably not up to the task of sorting out all these issues in a meaningful way such as a Civil Rights Amendment did for discrimination. But that is what is needed. We need to face the fact that commercial advantage and profits rule most of our society's behavior and that makes meaningful action now even more unlikely. Until we can have public discussions about acceptance of death and other limits to our desires, Americans cannot create a comprehensive foundation for a sane healthcare system.

    I have a Master’s Degree in Public Administration and worked in the healthcare reimbursement, quality and decision support information systems areas for over 18 years. I have been on and off 3 different health plans in the last 3 years, and now have no insurance.

    Here are some of my thoughts on the healthcare issues:

    - What if we work towards a system where we need health insurance only for serious conditions and operations. All other routine and intermediate care and testing should be affordable and budgetable for the average person. Houses and cars are not cheap, and we budget for those. Food is a relatively cheap commodity. Healthcare should be part of that mix of basic necessities - why should it be subsidized by the government or insurance?

    Insurance implies "free". Something that is free is not valued as much, and advice is not followed. Waste is an issue too: Doctors and hospitals sometimes do what they do because they can, not because they should or because doing it is best from the patient's point of view. Some patients waste everyone's time and money when they ignore their doctor's advice.

    I used to over-use healthcare because I had insurance. I think that insurance for preventive care does not give consumers incentives to use healthcare wisely and seriously.

    The only thing that the government should provide for free is healthcare education and coaching for whoever wants it and for welfare recipients.

    - What about a tiered approach to public insurance? All roles in healthcare need to make adjustments to their bad habits - people need to lead better lifestyles or pay more; physicians and hospitals need to charge reasonable prices and not do unnecessary procedures / charges, and public insurance needs to encourage healthy lifestyles.

    Tier 1 - Exclude basic preventative and routine diagnostic services from "health insurance" entirely; come up with reasonably priced doctors' visits and diagnostic fees so most people can afford preventative care. We should be able to budget for all our basic needs (housing, food, car, healthcare). We don't need another welfare program to bog down our economy. People who need to temporarily use welfare should have a healthcare allowance in their budget.

    Tier 2 - For non-routine diagnostics, more reasonable costs + basic insurance with a $50+ co-pay would balance out the costs.

    For operations or procedures, again, reasonable charges + co-pay + insurance.

    - Health and dental costs are insane. From what I've observed, part of the current costs are due to office expenses - liability insurance, insurance billing staff, regulations, paperwork, training and software, part is due to inefficient deployment of technology in our model of competition. And stressed out Physicians charge too much also.

    It seems to me that as technology improves and as physician / dentist practices compete, more and more technology costs are passed on to us consumers (after insurance takes its cut). Couldn't we have technology centers where an optimum number of diagnostic centers for a community are licensed, then results are electronically sent to the Primary Care Physicians and specialists?

  4. KattyBlackyard


    The best information i have found exactly here. Keep going Thank you

  5. Zashkaser


    Sorry but I don’t share most of these ideas.

  6. Gil Lancaster


    I want to clarify that the EMBRACE plan ( is not an option for the "Public Option" being discussed in Congress, but rather a plan for a comprehensive overhaul of our current healthcare system. Susan Mahoney’s concern that the insurance system is broken is only partially true; it is the whole system that’s broken. As long as our system is predominantly employer based, not portable, based on age, income level and health status, it can never be made to work. The insurance reform legislation that is being considered now will only patch a small part of a very broken system.

    The tier system in EMBRACE is only a part of an overall system that includes a politically and financially independent Board to oversee it and streamlined billing system that will significantly reduce the inefficiencies of the current system.

    At present (August 31st 2009), it is not certain what will emerge from Congress, but whatever does emerge will undoubtedly be only the beginning of a long road. We as health care professionals need to take initiative while we still can.

    If you want more information about our group or the EMBRACE plan, please visit our website ( or email me at to get updates.

  7. steve brandt


    public option is no more than a reworded fake. it's government controlled so go to ireland and germany . government has no bussiness interfering in healthcare like they did the auto industry .

  8. Gil Lancaster


    As healthcare providers who have taken keen interest in reforming our current healthcare system to benefit our patients, we can only give qualified support to the insurance reform plan now being considered in Congress. We say “qualified” because we cannot be sure exactly what form it will take or how it will affect our patients. What many once thought would be meaningful healthcare system reform, even President Obama now understands, will be nothing more than health insurance reform. But as Voltaire said, the best is the enemy of the good; and in this case health insurance reform may still be a good step forward in healthcare reform; if it is done right.

    By expanding access to the right type of healthcare services, even health insurance reform could improve healthcare for the entire population, without increasing (and maybe even decreasing) cost.

    What are the right types of healthcare services that could achieve these goals? Well the most important ones are for diagnosis and treatment of chronic conditions (such as diabetes and high blood pressure) that can lead to more severe -and costly- conditions later on. Emphasis on these “preventative” services as well as science driven treatment of life threatening illnesses would not only make our healthcare system more effective, it will also make it more affordable.

    The problem is that not all healthcare insurance gives the same access to these services. Currently, patients with Medicaid find that most private practice physicians will not accept their insurance, and end up relying on public clinics (which are often staffed by doctors-in-training), the emergency room or going without regular care. The end result is that many of these patients tend to put off medical care until their illness is more advanced and the work-up and treatment more complex; and significantly more expensive.

    The key is that Medicaid reimburses doctors very poorly, significantly below many practice’s break-even point. This is particularly true for office-based outpatient visits, so private practices cannot afford to extend their services to these patients.

    Our concern is that all five of the current proposals in Congress largely rely on Medicaid to extend coverage; a strategy that looks good on paper, but does little to improve the efficiency or effectiveness of the healthcare system. As can be seen in the Massachusetts experience, where they claim more than 97% of the population is covered, many of the newly insured complain that they cannot find a practice that accepts their insurance!

    Another proposal is the so-called “Public Option” plan (POP) designed to offer Medicare-like services to the entire population and compete with private insurance plans, with the hope of making them more efficient and affordable. Medicare, unlike Medicaid, offers more realistic reimbursements for providers. Although these reimbursements are somewhat lower than from the average negotiated private insurance plans, many providers find them acceptable since classic Medicare (before private insurance companies began to manage some plans through “Managed Medicare”) does not require as much overhead as when dealing with private insurance. It is this edge, in fact, that Congress and the Obama administration hope will make the POP competitive with private insurance.

    Our concern with the POP is that its success will largely depend on how many and which providers will accept it and how Congress will encourage participation by providers. A case in point is Connecticut’s Charter Oak Health Plan. Like the POP Charter Oak was established to help the uninsured who did not qualify for Medicaid or Medicare to purchase low cost insurance. To date, it is reported that over 2000 patients had signed up for the coverage through the plan but it is unclear how many physicians had signed up. Our informal poll of a large physician group found only one private internist accepting the plan. In fact, Charter Oak patients have reported to us that the only internists they could find were the ones working in “Medicaid Clinics”.

    Unfortunate we see a potential parallel between Charter Oak and the POP. To help keep costs low, the POP will likely lower reimbursements to doctors and hospitals. As long as these are similar to or more than Medicare, it is likely that most providers will accept the plan. If, however, the reimbursement is low or there is a lot of overhead, many physicians will opt out and this will make the POP less competitive with the private plans and therefore would fail. If on the other hand, Congress links Medicare with the POP (that is forcing the doctors to take either both or neither) then the U.S. may get two sets of doctors and hospitals: the “Private Providers” for the more privileged who can afford private insurance and the “Public Providers” for the rest.

    We need and want meaningful healthcare reform and we would even settle for health-insurance reform, but Congress needs to choose carefully; because with healthcare, it is a fine line between reform and deform.

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