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An alternative to the Affordable Care Act

Yale Medicine Magazine, 2017 - Winter


The Affordable Care Act (ACA) did not reform health care, argues cardiologist Gilead Lancaster, M.D., associate clinical professor of medicine and of nursing at Yale. It reformed insurance coverage.

In his new book, EMBRACE: A Revolutionary New Health-care System for the Twenty-First Century, Lancaster lays out a plan that would transform not only how Americans pay for health care but also how the nation sets clinical guidelines and funds research. Under Lancaster’s plan, politicians and lobbyists would lose much of their influence over the system. (EMBRACE stands for “expanding medical and behavioral resources with access to care for everyone.”)

Lancaster calls his proposal “uniquely American” in that it combines government funding and private insurance. Like a single-payer system, it would use tax revenues to pay for care, but only when illness or injury could threaten or shorten a patient’s life. But unlike in a single-payer system, private insurers would continue to play an important role by managing less critical care. Insurance would be cheaper than it is now, Lancaster said, as insurers would not need to cover the most serious health problems.

He says that under the plan, taxes would not increase and private insurers would finance 40 to 50 percent of total costs and would continue to profit. The book compares funding, oversight, and costs of his proposal with those of the current system and of single-payer systems.

In light of Donald Trump’s election and efforts to repeal the ACA, Lancaster said, his plan might be a viable alternative. It offers many tenets supported by Republicans—abolishing Medicare and Medicaid; removing requirements that businesses provide health insurance, and promoting “personal responsibility” for certain services. Some services would also be available between states, an idea proposed by Trump.

Lancaster‘s plan would also abolish such federal health care agencies as the Department of Health and Human Services, the Veterans Administration, and the Food and Drug Administration. The new system would replace them with a National Medical Board.

That board would oversee medical care and research. Congress would provide funding, but the board would control its budget and decisions. The board’s independence, Lancaster said, “should reduce a great deal of the politicization of health care.”

Lancaster was motivated by increasing insurance company control over health care, unfunded mandates, and the burden of paperwork. “It became harder and harder to practice individualized, evidence-based medicine,” he said. According to a 2014 estimate he cites in the book, it costs $58 to process insurance forms for a single visit to a primary care doctor.

Lancaster introduced his plan in a 2009 article in the Annals of Internal Medicine that he co-wrote with Yale colleagues Kimberly Ann Yonkers, M.D., professor of psychiatry, of epidemiology, and of obstetrics, gynecology, and reproductive sciences; and David L. Katz, M.D., M.P.H. ’93, a clinical instructor in internal medicine. He called the subsequent ACA “a relatively minor ‘fix’ to an archaic and hopelessly dysfunctional system … There is not a vision of what we are trying to accomplish.”

Lancaster knows that getting traction for the proposal is a long shot, but he has teamed up with 50 physicians, nurses, physician associates, politicians, and business people to promote it.

“The best way to explain EMBRACE is that it is a single-system health care system,” Lancaster said. “That differentiates it from a single-payer system and emphasizes its most important feature—unifying and simplifying our highly chaotic health care system.”

The book is available on Amazon.