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What's "Essential"?

By Allison Bell

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Officials throughout the United States are facing an emotional battle over what residents believe ought to go into an “essential health benefits” (EHB) package.

The Tennessee Department of Commerce and Insurance has created a documentary snapshot of public opinion on the EHB package by posting 153 pages of comments on the topic.  

In Tennessee, the commenters include health care providers, patients, caregivers, and members of the insurance and benefits communities.

The patients and caregivers are pleading for mercy.

Dr. David Buckman, who has a daughter who has a form of autism, asks policymakers to consider putting services that help people with autism cope with adult life in the EHB package.

Today, “there are few resources in our state to assist in these challenging areas for adults with autism,” Buckman says. “Right now they are pretty much ‘on their own,’ sink or swim, in our state. As family we are doing out best to help [our daughter] ‘swim’ but the going is pretty rough on our own.”

The members of the insurance and benefits communities are asking for help with costs and red tape.

C. Gregg Conroy, a human resources specialist, acknowledges in his letter that the individuals asking policymakers to include various conditions, treatments and drugs in the package have good intentions.

But, “my concern is that, however well-intentioned, these individuals and the organizations/interests they represent are looking through a narrow lens of coverage for their cause and are not considering the broader implications of the costs associated with including all of these suggested benefits,” Conroy says. “As a long-time employee benefits and human resources professional I am concerned that they are not considering the critical element of overall affordability as they support their focused interests.”

The EHB Program

The Tennessee department is developing EHB package standards to comply with the EHB provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA).

PPACA opponents continue to fight in the courts, in Congress, in state legislatures and at the polls to repeal part or all of PPACA and block implementation of the act. 

If the law takes effect on schedule and works as drafters expect, it will require all individual and small group major medical plans to offer the standardized EHB package by 2014, to help consumers compare coverage and reduce gaps in coverage.

The U.S. Department of Health and Human Services (HHS) has asked each state to design its own EHB package.

A state is supposed to start by looking at the benefits offered by the three largest Federal Employee Health Benefits Program plans offered in the state, the three largest state employee benefit plans, the three largest small group commercial health plans, and the largest commercial health maintenance organization (HMO) plan.

The EHB benchmark plan chosen is supposed to provide benefits in 10 different areas, including ambulatory patient services, emergency services, hospitalization services and pediatric services.

In the real world, experts say, states may not end up with much flexibility in shaping EHB packages. In Kansas, for example, Milliman told regulators there that the benefits provided by the EHB benchmark candidate plans are similar.

In Tennessee, Julie Mix McPeak, the insurance commissioner, has been trying to comply with the EHB package development rules by holding outreach meetings and seeking public comments.

Once Gov. Bill Haslam, R, approves an EHB benchmark proposal, she will enact an administrative rule designating the EHB benchmark plan and describing the EHB package, officials say.

The Comments 

Joseph Interrante of Nashville Cares, a group that represents about 2,500 people with HIV and AIDS, writes that subtle details in the EHB benchmark and package can  have a big effect on people’s lives.

A poorly designed “formulary,” or covered drug list, could be devastating for people with HIV, Interrante says.

If, for example, a formulary included just one anti-HIV retroviral drug, or just a small number of retroviral drugs, that could ruin a patient’s efforts to keep HIV under control, Interrante says. 

“People living with HIV and AIDS rely on a minimum of three drugs from the antiretroviral drug class to effectively suppress the virus,” Interrante says. “Because the specific combination of drugs varies significantly by individual health history, plans that cover only one or even a few drugs in each category or class covered by the benchmark would not support the current standard of HIV care.”

Regulators need to include detailed provisions listing what retroviral drugs a formulary include and limiting barriers to access for those drugs, Interrante says.

Conroy, the human resources specialist, encourages regulators to weigh the cost of every suggested EHB provision.

“While it is easy to say yes to each legitimate health concern, it is also a legitimate concern to consider the cost impact of all the ‘yesses’ on both employer-provided health benefits and the individual policies that will be available, on the exchanges or otherwise,” Conroy says. “Affordability must be factored into the state’s decisions…. or even the ‘Bronze’ level coverage may be out of the reach of those who need it.”

The department also received comments from members of the public who oppose any effort by state officials to implement any part of PPACA, including the EHB package requirements.

“Just say no,” says Ruth Ann Wilson. “Do not bring National Health Care to Tennessee. Leave us alone. The American public did not want this ‘forced’ monstrosity and the federal government was told not to pursue this ‘forced’ program. Yet, the powers that be will not stop, but continue to try some ‘back door approach’ to come to the state level.”

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