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On the Third Hand: What's Essential

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To me, it looks as if the idea that society can let poor, uninsured people with serious health problems die on the sidewalk is gaining momentum.

The idea that we can take benefits away from those folks but that some hazy someone will do something about sick people on the sidewalk seems to be much more popular.

To me, it seems, though, as if the philosophy that really dominates health care finance in the United States is that just about anyone who is really cute, young, brave, or otherwise attractive can use media coverage to get coverage for whatever treatment he or she thinks might possibly increase his or lifespan by about two hours or more, no matter what the cost be.

On the one hand: I’m a softie. I want everyone to have every access to every imaginable treatment. I read those stories and want someone to do something.

On the other hand: Offering all reasonably media-friendly people with serious health problems warm and fuzzy assurances that every life is precious, and that we’ll spend whatever we have to spend to give everyone the best possible medical care, probably hastens the arrival of the day when the system breaks down and we have no choice but to dump people on the sidewalk. Running an insurance company is all about the painful task of recognizing that the maximum amount of supply that can really be available will always, always, always constrain the amount of demand that can be fulfilled, no matter how fervently we might wish otherwise. Rebelling against the physical constraints by saying “yes” to pleas that can’t realistically be fulfilled is foolish.

On the third hand: The battle over the “Essential Health Benefits” (EHB) package that will (apparently; Congress and any court challenges still in the pipeline permitting) be created by the Patient Protection and Affordable Care Act of 2010 (PPACA) may be the place where the claws of demand will go at it with the claws of bloody in vicious, bloody combat until the political landscape is covered with dazed, whimpering interest groups.

The system created by PPACA would use the EHB as a yardstick consumers and others could use to measure the actuarial value provided by health plans. 

The California Department of Insurance recently gave us a peek at what the gladiatorial combat might look like holding an EHB hearing.

The department posted a comparison of the benefits offered by 10 possible benchmark coverage options and also has posted a transcript of the EHB hearing.

At one point, a witness got up to talk about applied behavioral analysis (ABA) therapy for children with autism.

ABA can cost $30,000 or more per year child. Some people don’t like it, but other people say it is just about the only treatment that makes much of a difference. California and other states have adopted ABA coverage mandates. Federal officials appear to be suggesting that the EHB benchmark plan should be more of a Chevy than a Cadillac, and that the EHB plan might exclude ABA benefits.

The witness said — in defense of keeping ABA benefits in the EHB plan — that “autism is a condition that affects one in 88 children and becoming more and more prevalent.”

Think of how heart-breaking it would be to keep ABA therapy out of the EHB and through that move reduce the likelihood that tens of thousands of children will get the care they need to live happy, fulfilling, taxpaying lives.

But how realistic is it to think that society can really pay $30,000 per year for ABA therapy for, say, 1% of all children for 10 years. Maybe 400,000 children per year — $12 billion in spending per year on just one type of treatment for one type of condition. 

And maybe that’s a pretty easy question. Maybe society should obviously spend that money, because the patients are children, and, in many cases, providing effective therapy for those children could more than pay for itself by reducing the likelihood that the children will end up institutionalized.

But I think there hundreds, maybe thousands of tougher, more complicated, more heart-breaking EHB battles yet to come, and probably more battles of that nature outside the EHB package design framework once PPACA takes full effect.


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