The Expanding Medical and Behavioral Resources with Access to Care
for Everyone Health Plan
Gilead I Lancaster, MD; Ryan O’Connell, MD; David L. Katz, MD, MPH; JoAnn E. Manson, MD, DrPH; William R. Hutchison, MSIR;
Charles Landau, MD; and Kimberly A. Yonkers, MD, for Healthcare Professionals for Healthcare Reform
Healthcare Professionals for Healthcare Reform is a group of physicians
and others interested in health care reform who, recognizing the ur-
gent need for change, convened to propose a universal health care
plan that builds on the strengths of the U.S. health care system and
improves on its coverage, efficiency, and capacity for patient choice.
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.
The entire system would be overseen by a quasi-governmental,
largely independent organization known as “The Board,” which
would resemble the Federal Reserve and interact with U.S. Depart-
ment of Health and Human Services agencies to oversee imple-
mentation and coverage.
By building on the current health care system while introducing
other features and efficiencies, the Expanding Medical and Behav-
ioral Resources with Access to Care for Everyone (EMBRACE) plan
for universal health insurance coverage offers several advantages
over alternative plans that have been proposed.
Ann Intern Med. 2009;150:490-492.
For author affiliations, see end of text.
This article was published at www.annals.org on 3 March 2009.
in the bottom third for important measures, such as infant
and maternal death rates and life expectancy (2). Current
interest in U.S. health care system reform focuses on the
expansion of health insurance to more individuals (3), but
many proposals lack the structure that would improve the
health of Americans in an affordable, efficient, and trans-
parent way that maintains or even expands patient choice
Healthcare Professionals for Healthcare Reform is a
group of physicians, nurses, medical technicians, hospital
administrators, public health experts, health care econo-
mists, business leaders, politicians, and patients who, in-
spired by the realization that conversations about health
care reform lack input from health care professionals, con-
vened to propose a universal coverage plan that builds on
the strengths of the U.S. health care delivery system and
improves on its efficiency and capacity for patient choice.
Our plan, called Expanding Medical and Behavioral Re-
sources with Access to Care for Everyone (EMBRACE), is
based on a tiered approach to health care and on the tenet
that the entire population can be covered for life-sustaining
and health-promoting (basic) health care, with additional
coverage available for those who desire it.
he United States spends twice as much per capita on
health care as other developed countries (1) but ranks
THE EMBRACE 3-TIER SYSTEM
The EMBRACE system would be composed of 3 tiers
Tier 1, the base level, would cover the entire popula-
tion from cradle to grave. It would include all medical,
surgical, and psychiatric therapies considered to be life sav-
ing, life-sustaining, or preventive on the basis of the best
evidence (from the medical literature and expert opinions).
A government-subsidized account similar to Medicare
would provide the funds, with the elimination of all other
public insurance. The method of raising this revenue could
be similar to the present funding of Medicare (such as the
Federal Insurance Contributions Act tax) and Medicaid,
but because businesses should receive substantial savings
after initiation of this plan, additional sources of revenue
may be considered. These could include payroll taxes (in-
dexed to salary), a tax on businesses on the basis of the
number of employees (and their wages), or a combination
of these. Because the number of items covered by Tier 1 in
this new system would be substantially less than what
Medicare and Medicaid currently cover, funds would be
available to redistribute to achieve universal Tier 1 cover-
age. We believe that this should be a revenue-neutral redis-
tribution of public funding.
Tier 2 would cover all therapies considered to help
with quality of life, as well as some diagnoses or services
that do not have sufficient evidence for a Tier 1 indication.
Private insurance carriers would administer Tier 2 ser-
vices. The private insurance carriers would be allowed to
offer a limited number of plans that would be developed by
Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . 498
Related articles. . . . . . . . . . . . . . . . . . . . . . . . 485, 493
Dialogue on health care reform
Annals of Internal Medicine
490 © 2009 American College of Physicians
an oversight board (see next section), similar to the Medi-
gap Plans A to L now stipulated by the Centers for Medi-
care & Medicaid Services (5). Although each insurance
carrier would not have to offer all the plans, the offered
plans would cover all the services stipulated by the board.
A major advantage of this approach is that consumers (ei-
ther employers or individuals) can compare the price of the
Tier 2 plans can be broad (covering most Tier 2 ser-
vices) or can be customized for specific groups, such as a
geriatric plan that covers extended care facilities but not
fertility care; a heavy laborer plan that includes chiropractic
therapy; or a worker’s compensation plan purchased by
employers, employees, or unions.
Tier 3 would apply to all medical and surgical issues
considered luxury or cosmetic, such as radial keratotomy or
botulinum toxin treatments. Funding for Tier 3 would not
be covered under the EMBRACE system—as in the cur-
rent system—and all bills would go to the patient.
Pharmaceuticals will have similar tier assignments for
medical coverage: Tier 1 would include formulations and
therapies that treat or prevent serious illnesses and would
mostly be paid for by public funds or be heavily subsidized.
Tier 2 would apply to drugs and therapies that enhance
quality of life and would be covered by private insurance.
Tier 3 would be for luxury items.
Our proposed system would be overseen by a panel of
physicians and other health care professionals, public
health experts, and economists who specialize in health
care, known as “The Board.” The Board’s mission would
be to promote the health of Americans in a socially respon-
sible and economically sound way. Similar to former Sen-
ator Tom Daschle’s recently proposed “Federal Health
Board” (6), it would be a quasi-governmental organization
that resembles the Federal Reserve, which should make it
less beholden to political pressures. It would be headed by
a chairperson who would be appointed to a 10-year term
by the president and require Senate confirmation.
The Board would have oversight of the Centers for
Medicare & Medicaid Services and input into the U.S.
Food and Drug Administration and the National Institutes
of Health. Using already established Diagnosis-Related
Group, Ambulatory Payment Classification, and Interna-
tional Classification of Diseases codes, the Board would
decide which diagnoses and services are covered by Tier 1,
2, or 3 on the basis of medical importance (by using evi-
dence-based data, including practice guidelines developed
by expert medical panels, Cochrane Library reviews, and
other sources), public health considerations, and economic
effect. These assessments would be updated periodically.
The Board’s authority to direct the National Institutes
of Health and the U.S. Food and Drug Administration
would allow it to direct research that focused on the ther-
apeutic issues that it needs to achieve its mission (to im-
prove the health of the country and reduce costs). For
example, if evidence supporting a particular treatment is
based on expert consensus, the Board may direct the U.S.
Food and Drug Administration (for a medication or de-
vice) or National Institutes of Health (for an intervention)
to request applications for studies that will allow better tier
Among the prerequisites to the implementation of this
system would be delineation of the specific relationships
between the Board and existing agencies within the U.S.
Department of Health and Human Services, in particular
the U.S. Food and Drug Administration and the National
Institutes of Health. Some reorganization of these govern-
ment agencies might be warranted to optimize interagency
To address the excessive overhead involved in claim
submission by providers and insurance companies, the
Board would create a universal reimbursement form that
would be implemented electronically by using a Web-
based tool available to hospitals and physician offices. This
form would be the only form of billing for all providers
and would be Internet-based and simple to use. Form data
would be transmitted to a central billing system, which
would decide whether the condition or service is Tier 1,
Tier 2, or Tier 3. Tier 1 services would be reimbursed
directly to the provider. Tier 2 services would trigger a
computerized search for insurance coverage; if insurance is
found, the insurance carrier would be billed and if not, the
patient would be billed. Bills for Tier 3 would be sent
directly to the patient.
To help with questions about the assigned tier for a
particular service, the central billing system would have a
billing inquiry feature available to providers and consumers
to allow inquiries about tier assignment in advance.
ADVANTAGES OF THE EMBRACE SYSTEM OVER
Ideally, a single-payer model would accomplish the
goals of improving the health of the nation with a uniform
and universal system of health care delivery. One such pro-
posed system is the “Physicians for a National Health Pro-
gram” model. Proposed in 2003 (7) and introduced to
Congress in 2007 as H.R.H. 676 (8), the plan advocates an
expanded Medicare system that would exclude all private
insurance payers and eliminate all for-profit hospitals and
Like our proposal, the Physicians for a National
Health Program plan would provide patients universal ac-
cess to approved medical care that would be paid by a
national health insurance agency. However, if the desired
treatment or service in the Physicians for a National
Medicine and Public Issues
The EMBRACE Health Plan
7 April 2009 Annals of Internal Medicine Volume 150 • Number 7 491
Health Program system is not approved, patients will most
likely find ways outside of the system to obtain that service.
As in other countries with a single-tiered health care sys-
tem, use of unapproved services may lead to a de facto
multitiered system (9). In these latter systems, parallel out-
side enterprises often grow, become private, and compete
with the publicly funded system—usually to the detriment
The EMBRACE plan encourages private (Tier 2) par-
ticipation for services that are not publicly financed. The
existence of this integrated private tier would allow for
fewer covered services in Tier 1, which in turn would re-
duce the public financial burden. In addition, allowing all
the tiers to be part of the same system would allow patients
to see the same provider for all services and render all
services subject to the same ultimate oversight. Politically, a
system that continues to allow private, for-profit insurance
and some degree of free market forces would be more via-
ble than a system that attempted to control or eliminate
Our plan preserves many of the favored features of the
present system, such as a provider’s ability to offer all ser-
vices even if they are Tier 2 or Tier 3, which would keep
the new system more familiar to the patient and provider
and in turn facilitate the transition to it.
The EMBRACE plan offers universal coverage for es-
sential health care and promises to reduce mortality and
morbidity and encourage preventive care. The increased
efficiency of the system should allow hospitals to reallocate
funds to other services, such as health information technol-
ogies, and allow health care professionals more clinical
time. For the patient, the system offers universal coverage
for basic health care needs, transparency for Tier 2 cover-
age, and complete portability of all insurance coverage.
Employers would be relieved of the financial burden of
coverage for most services but retain the option to offer
Tier 2 coverage as a benefit to employees. Finally, insur-
ance providers would benefit from the elimination of the
financial risks associated with Tier 1 services, and the sys-
tem at large would benefit from centralized billing and a
reduction in administrative overhead.
From Bridgeport Hospital, Bridgeport, Connecticut; Yale School of Pub-
lic Health and Yale School of Medicine, New Haven, Connecticut;
Brigham and Women’s Hospital and Harvard Medical School, Boston,
Massachusetts; West Virginia College of Business and West Virginia
University, Morgantown, West Virginia; and Columbia University Col-
lege of Physicians and Surgeons, New York, New York.
Acknowledgment: The authors thank Harlan Krumholz, MD, SM, Ha-
rold H. Hines, Jr., Professor of Medicine and Epidemiology and Public
Health, Yale School of Medicine, New Haven, Connecticut.
Potential Financial Conflicts of Interest: Grants received: K.A. Yonkers
(Pfizer, Eli Lilly, Wyeth).
Requests for Single Reprints: Gilead I Lancaster, MD, The Heart
Institute at Bridgeport Hospital, 267 Grant Street, Bridgeport, CT
06610; e-mail, firstname.lastname@example.org.
Current author addresses are available at www.annals.org.
1. Chen L, Evans D, Evans T, Sadana R, Stilwell B, Travis P, et al. The World
Health Report 2006: Working Together for Health. Geneva: World Health Or-
2. Schroeder SA. Shattuck Lecture. We can do better—improving the health of
the American people. N Engl J Med. 2007;357:1221-8. [PMID: 17881753]
3. Oberlander J. Presidential politics and the resurgence of health care reform. N
Engl J Med. 2007;357:2101-4. [PMID: 18032761]
4. Oberlander J. Is premium support the right medicine for Medicare? Health Aff
(Millwood). 2000;19:84-99. [PMID: 10992656]
5. Centers for Medicare & Medicaid Services, National Association of Insur-
ance Commissioners. Choosing a Medigap Policy: A Guide to Health Insurance
for People with Medicare. Baltimore, MD: Centers for Medicare & Medicaid
Services; 2008. Accessed at www.medicare.gov/publications/pubs/pdf/02110.pdf
on 16 February 2009.
6. Daschle T, Greenberger SS, Lambrew JM. Critical. What We Can Do About
the Health-Care Crisis. New York: St. Martin’s Pr; 2008:169-80.
7. Woolhandler S, Himmelstein DU, Angell M, Young QD; Physicians’ Work-
ing Group for Single-Payer National Health Insurance. Proposal of the Physi-
cians’ Working Group for Single-Payer National Health Insurance. JAMA. 2003;
290:798-805. [PMID: 12915433]
8. H.R. 676, 110th Cong. (2007).
9. Lyall S. Paying Patients Test British Health Care System. New York Times.
21 February 2008. Accessed at www.nytimes.com/2008/02/21/world/europe
/21britain.html on 16 February 2009.
Medicine and Public Issues
The EMBRACE Health Plan
492 7 April 2009 Annals of Internal Medicine Volume 150 • Number 7
Current Author Addresses: Drs. Lancaster and O’Connell: The Heart Download full-text
Institute at Bridgeport Hospital, 267 Grant Street, Bridgeport, CT
Dr. Katz: Yale Prevention Research Center, Griffin Hospital, 2nd Floor,
130 Division Street, Derby, CT 06418.
Dr. Manson: Division of Preventive Medicine, Brigham and Women’s
Hospital, Harvard Medical School, 900 Commonwealth Avenue, 3rd
Floor, Boston, MA 02215.
Mr. Hutchison: 7 Overlook Drive, Newtown CT 06470.
Dr. Landau: Connecticut Heart and Vascular Center, 2979 Main Street,
Bridgeport, CT 06606.
Dr. Yonkers: Yale School of Medicine, 142 Temple Street, Suite 301,
New Haven, CT 06510.
Annals of Internal Medicine
W-88 7 April 2009 Annals of Internal Medicine Volume 150 • Number 7