McCarthy D, Chase D; AcademyHealth. Meeting (2003 : Nashville, Tenn.).
Abstr AcademyHealth Meet. 2003; 20: abstract no. 52.
Issues Research, Inc., PO Box 220, Durango, CO 81302 Tel. (970) 259-7961 Fax (703) 997-8221
RESEARCH OBJECTIVE: Assuring that everyone has access to essential health care is a widely shared value in western democracies. With the ranks of the uninsured again rising and States facing mounting pressure to reduce public spending, some policymakers and advocates are calling for a focus on "basic" health care benefits, yet there is very little agreement on what that concept means. This paper synthesizes the experiences of States that have defined basic benefit packages and the views of health policy experts on the prospects for defining essential health care benefits in American health care more broadly. STUDY DESIGN: Literature review and telephone interviews with approximately 50 experts including high-level Congressional aides, State agency administrators, former State legislators, consumer and industry association leaders, physician leaders, employee benefit managers, national consultants, health services researchers and economists, and an ethicist. POPULATION STUDIED: United States. PRINCIPAL FINDINGS: Discussion of essential health care is considered too politically divisive at the federal level, where the focus is on seeking consensus for financing mechanisms to achieve incremental coverage expansion. Defining essential health care is likely to devolve to the states in the design of public programs and to the private sector in the design of coverage for those eligible for tax credits. Several states that successfully defined basic benefits for Medicaid or subsidized insurance programs delegated decision-making to administrators or a commission; states that established a cost goal found that it focused stakeholders on prioritizing the most important services. Some experts believe that opportunities for public conversations are needed to develop consensus. Others fear that a public process will become dominated by special interests or expose social divisions, arguing for methods to better inform consumer decision-making. Yet there may be opportunity to inform the design of both public and private benefit standards as well as consumer choice through recommendations of expert bodies. The benefits package and the rationale for coverage and exclusions must be understandable to the layperson and accepted as reasonable and adequate in meeting needs. Benefits must be tailored to the population served, e.g., reduced cost-sharing for those with low-income and additional benefits for those with special needs. Prioritizing benefit service categories is easier and more understandable than ranking specific treatments, but does not allow identification of the most essential care. Some experts believe a good place to start is limiting coverage to appropriate care (benefit outweighs risk) while others believe that cost-effectiveness (weighing benefits, costs, and social values) must be considered. CONCLUSIONS: Both evidence and judgment must play a part in defining essential health care benefits given social concerns and the limited scientific knowledge base. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: The need for defining essential health care benefits is likely to be most acute among states as they wrestle with benefits design for public programs, and among private plans designing benefits to attract businesses and individuals eligible for tax credits. Methods should incorporate both evidence and public/patient preferences in a common sense way to determine the most appropriate and/or cost-effective benefits to improve population health and satisfaction.
Publication Types:
Keywords:
- Cost Sharing
- Cost-Benefit Analysis
- Delivery of Health Care
- Health
- Health Benefit Plans, Employee
- Health Expenditures
- Health Policy
- Health Services
- Health Services Needs and Demand
- Humans
- Insurance Benefits
- Insurance, Health
- Medicaid
- Medically Uninsured
- National Health Insurance, United States
- Private Sector
- State Health Plans
- Taxes
- United States
- economics
- hsrmtgs
Other ID:
UI: 102275040
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