For months, government officials, health industry professionals, policy experts and politicians have been debating what “essential benefits” should be covered by health plans beginning in 2014 that participate in state insurance exchanges and in Medicaid programs. The package, required by the health law, has raised some critical questions:

Should the package set a national standard for health plans to cover a comprehensive set of benefits? Or is it more important that states have flexibility to determine what is “essential” based on their own markets. And how do issues of heatlh care costs, affordability and quality fit into the discussion? For months, questions like these have been part of the implementation debate.  

Answers will begin to take shape with an Institute of Medicine report, which was requested by HHS and is expected to be released in the next weeks. HHS regulations are expected to follow later this fall. 

In the mean time, KHN asked a group of experts what core principles should steer the development of this rule if it is to both benefit consumers and the marketplace. Commentaries follow from Utah Rep. James Dunnigan; A. Mark Fendrick, who directs the University of Michigan Center for Value-Based Insurance Design; and Debra L. Ness, president of the National Partnership for Women & Families.  

Ness

The Essential Benefit Package Americans Need

Debra L. Ness writes: “The development of this package is a balancing act between making sure Americans have access to the kinds of health care services they need most and keeping this coverage affordable. If the administration adopts a strong essential benefit package, beginning in 2014, for the first time in history all new insurance plans for individuals and small businesses will cover needed services, including private insurance policies that are certified and offered in state health insurance exchanges.” Read the column. 

Fendrick

Clinical Nuance Essential To Essential Benefits Package

According to Dr. A. Mark Fendrick, “[t]he debate over essential health benefits has been largely framed as a trade-off between cost and comprehensiveness: the more expansive the benefit, the more expensive the coverage. However, benefit plans can be enhanced by incorporating a third dimension to the discussion: something we call clinical nuance.” He focused on how, if considered in the development of the package, the concepts behind value-based insurance design can help health control health care costs and improve quality. Read the column.

Dunnigan

Utah State Rep. James Dunnigan writes that the “secretary of Health and Human Services must define ‘essential benefits’ in a way that includes 10 broad categories of services and is equal in scope to benefits provided under a typical employer plan. The problem is that what’s ‘typical’ varies both within and across states, and even varies by employer and plan type. … As a result, if the secretary establishes an inflexible, nationally uniform definition of essential benefits, states and consumers could lose in several ways.” Read the column.