Strike the right balance on essential health benefits

Under the health system reform law, determining essential health benefits is one of the key balancing acts for policymakers.

If the list of benefits is too large, insurers may find themselves covering everything under the sun, and that can drive up costs. If the list is too small, patients may go without the necessary care they need.

With so much on the line, the American Medical Association and other physician organizations have given their input to the Dept. of Health and Human Services. HHS oversees the process to determine what minimum benefits coverage will be provided by health plans through insurance exchanges and by many plans outside such exchanges, starting in 2014.

In December 2011, HHS added the states to the balancing act. Each state can weigh the coverage options of existing health plans within the state and select one to be a benchmark for the mandatory minimum package that provides patients with the essential health benefits. States should have some flexibility in their selection, because what makes sense for coverage for patients in Alaska may be different for patients in Florida.

However, when it comes to certain vulnerable populations such as children, some minimum benefits are vital and should be the same everywhere. Covering children from an early age makes sense not only from a public health standpoint but also from a cost standpoint. Keeping them healthy early on may prevent serious health problems from developing later in life.

The AMA has told HHS that it generally supports giving states flexibility to select the essential benefits package for adults through the benchmark approach. However, the AMA has cautioned that relying solely on that approach for children’s coverage is unwise.

In a late January letter, the AMA said a benchmark plan should be required to use Medicaid’s basic child health benefits, known as the Early and Periodic Screening Diagnostic and Treatment program. That would enable children to get the immunizations, screenings and other services to keep them healthy.

Comprehensive preventive care under EPSDT includes physical exams, vision care and mental health screenings. Some children, particularly those with special health needs, have coverage gaps in private health plans that would not exist under the EPSDT model.

Another main sticking point on essential health benefits, addressed in the letter, is prescription drug coverage. The HHS proposal calls for health plans to cover at least one prescription per drug class.

However, that does not match the Medicare requirement of at least two medications per class. Medicare requires more than two drugs if the medications have therapeutic advantages in efficacy and safety.

For some patients, a particular drug isn’t going to work, and they will need an additional option. That’s why Medicare covers at least two drugs in every class, and that’s why health plans should be required to cover at least two drugs as well.

The promise of essential health benefits at the start of the process carries with it the responsibility for a credible and sustainable offering by the end of it. HHS has selected the path it intends to follow — one that should end up in the right place but that requires care in avoiding some wrong turns along the way.