Health for life

Remember that Affordable Care Act (ACA) "essential health benefit (EHB)?" 

While Disease Management Care Blog doesnt want to be reminded about it either, the topic bubbled into the health policy news cycle thanks to this sleeper bulletin recently released by HHS. Recall, despite the ACA requiring an approach based on a "typical" insurance plan covering ten categories of services, that the law set the stage for a requirement that every U.S. health insurer would have to potentially cover an expansive, complicated, expensive and controversial suite of services in each and every health insurance policy.  Any insurance plan not meeting the EHB would be excluded from the exchanges.

While the DMCB feared the unable-to-say-no amateurs in HHS would stumble their way into an unaffordable and one-size-fits-all package, it appears theyve blinked.  Thats because theyve discovered that the ACA misread things: while insurance policies typically cover a core set of services, they vary in coverage of other services.  That includes dental care, acupuncture, bariatirc surgery, hearing aids, tobacco cessation, in-vitro fertilization, certain autism services, a variety of mental health and substance use disorders and habilitative (yes, that was a new one for the DMCB too) services.

How does HHS intend to reconcile this?

"We intend to propose that EHB be defined by a benchmark plan selected by each State."  

Whoa.

In other words, there would be 50 EHBs.  As the DMCB understands it, each would be calculated using an intra-state combination of the largest small group plan, any of the largest thee state employee plans, any of the large three national FEHBP plans and the largest commercial plan.  If a state doesnt calculate the benefit, the Feds intend to use the one used by the largest small group insurance plan.  If the calculation doesnt include sufficient coverage in all the ten categories, the ultimate default is using whatever is in the states largest FEHBP plan.

Business groups and state leadership will probably find the local state-based approach a more palatable alternative, while some professional (for example) and patient advocacy (for example) may be disappointed.

The Disease Management Care Blog spent the day navigating the halls of Congress.  The DMCB discerned a perence for black-toned suits and dresses among many of the staffers, making it think in was either in a "Men In Black" movie or that the depths of D.C.s doldrums worse than even it imagined.

As further evidence of the dysfunction, the DMCB was told that the "clean-up" bills that typically follow every major piece of legislation are unlikely to get anywhere anytime soon.  The inevitable additions, deletions and clarifications that are usually necessary to align any newly minted U.S. law with its original legislative intent are typically tackled over the following years, but not for the Affordable Care Act.  Cleaning up the ACA is being stymied by the Republicans, whose only solution to any problem in the law is to repeal it, as well as the Democrats, who are reluctant to introduce any bill that could open a Pandoras Box of crippling orms.  That no-go approach has also spilled onto other unrelated health care legislation.

And speaking of no-go, it also took the DMCB twice as long to get out of downtown DC thanks to traffic that was stuck somewhere between paralyzed and gridlock. 

Funeral garb. Legislative brainlock.  Automotive immobility. Merely a coincidence?  You be the judge.

Image from Wikipedia

While the Disease Management Care Blog has had more than its share of doubts about the Affordable Care Act, it ultimately agreed that the "individual health insurance mandate" may be a necessary - if perilously unconstitutional - requirement.  Conventional wisdom says that unless everyone buys into the system, healthy persons will forgo the expense of insurance. That means only the sick will pay for insurance that ultimately cannot cover the collective cost of their illness. That will lead to a rapidly escalating prices, otherwise known as a "death spiral."

And thats why, now that the mandate has been taken up by the Supreme Court, Obamacares supporters fear that striking the mandate could unravel everything.

Which is why the DMCB found this "dont worry, be happy" analysis by Lewin Groups John Sheils and Randall Haught very interesting. They say Obamacare can still succeed without the mandate.

Based on complicated economic modeling using a mix of inputs, methods and assumptions, they found, in contrast to the widely quoted Congressional Budget Offices mix of inputs, methods and assumptions, that

1) many persons without health insurance would take advantage of the ACAs generous premium subsidies, and

2) an open enrollment window limited to one month a year would blunt the impact of persons "gaming" health insurance by only enrolling when theyre sick. 

While insurance would not be universal, the Lewin authors estimate that between 21 and 24 million Americans who were previously uninsured would become insured.  While premiums could increase by 12.6%, the premium subsidies would help put the word "affordable" in the ACA. 

To further buttress their argument, they point out that in 1993 New York State required its health insurers to accept all applicants regardless of health status.  Despite many dire predictions, there was no spiral and no documented loss of coverage.

What can the DMCB conclude after reading this?  Its easy: no one really knows what is going to happen in 2014 with or without the mandate. 

It looks like there is only way to find out.