Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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3 Policy Foundations and Criteria for the EHB
3 Policy Foundations and Criteria for the EHB
Pages 47-58
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From page 47... ...
The committee's framework of policy foundations and related criteria is consistent with the goals of the Patient Protection and Affordable Care Act (ACA) and those initiatives contained within it, such as HHS's National Quality Strategy1 -- to expand access to health insurance, to improve the quality of care, to improve the health of individuals and communities, and to reduce the cost of care.
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From page 48... ...
With respect to the ACA, new markets are being developed for health insurance products that will include the EHB. Decisions about the scope of coverage in the EHB package and product benefit design will affect its success in the market -- both whether it can be sustained with private and public funds over time and whether a sufficient number of insurers will participate in the exchange, or otherwise opt to exclusively sell plans not subject to the EHB (e.g., those with a grandfathered status, or self-insured in the large employer market)
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From page 49... ...
. The individual mandate was envisioned as the most effective means to maximally broaden the insured population base to help address the current state of cross-subsidization of the uninsured by the insured and minimize adverse selection, while also gaining insurance industry acceptance for the insurance reforms contained in the ACA (Chandra et al., 2011; McGlynn et al., 2010)
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From page 50... ...
In Chapter 2, there is a brief overview of cost drivers for health care spending and insurance premium growth, as well as discussion of unwarranted preference and supply-sensitive variations in care. Market pressures can lead to unnecessary utilization of high-cost services and items without a commensurate benefit -- for example, marketing by vendors directly to patients of profitable services that have low health gains over alternatives (e.g., virtual physical exams, high-cost pharmaceuticals)
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From page 51... ...
Compassion is consistent with the health insurance function of protecting against an imbalance in 5. individual risk, requiring that health care resource allocation transcend the formulaic by incorporating flexibility and responsiveness to extraordinary individual circumstances and informing itself on such individual variations (AMA, 2004)
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From page 52... ...
Evidence-Based Practice Evidence drives the evolution of medical practice -- from its origins rooted in mythology, to observation, randomized trial, systematic review, and large-scale personalized modeling. In directing this move from the "usual and customary" and "standard of practice" to mixed models of evidence- or expert-based practice, evidence-based medical practice improves the quality of clinical decision making.
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From page 53... ...
Obstacles to increased use of evidence in health benefits design include a perceived lack of sufficient evidence, inability to communicate -- with credibility and transparency -- to consumers the rationale behind perceived limita tions on coverage, inadequate benefit design description, financial and administrative considerations, and resistance to change among providers, vendors, and consumers (Bernstein, 2010; Santa and Gibson, 2006)
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From page 54... ...
suggests that population health can be improved when health insurance coverage is extended to the uninsured (a 10 percent increase in insurance coverage of a state's population was estimated to reduce mortality by 1.69-1.92 percent)
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From page 55... ...
The committee was acutely aware that the affordability of the EHB package would affect market response and has more to say in Chapter 5 on how a projected national average premium can guide EHB package development. The committee recognizes the intent of the ACA to maximize the number of people who are meaningfully insured and thereby the implicit goal embedded in the CBO scoring of the health reform bill for the potential reduction in the number of uninsured and take up of coverage through private means.
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From page 56... ...
The committee supports an evidence-based and value-based approach to coverage of health services as desirable to maximize the health gains of such services as well as provide patients with the best choice of safe and effective treatments. This argues for development of a shared EHB evidence base, monitoring of access to designated EHB coverage so that benefits supported by evidence are available to those who need them, and being encouraging to new modes of delivery or insurance design that foster value.
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From page 57... ...
. Together, these policy foundations, principles, and criteria comprise the committee's framework for defining and revising the EHB package, in a manner consistent with the ACA.
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From page 58... ...
2008. Does extending health insurance coverage to the uninsured improve population health outcomes?
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