Debate flares over what "essential" benefits include

House health reform legislation would mandate a basic coverage package all plans must offer. But some organizations question if that includes abortion.

By — Posted Aug. 10, 2009

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A provision in the pending House health system reform bill details a basic benefits package that eventually would become the standard for all plans, public and private. But unresolved questions about the design and scope of the "essential benefits package" have sparked a controversy among some health policy organizations, most notably over the issue of abortion services.

The Family Research Council, an anti-abortion organization based in Washington, D.C., maintains that abortion could be considered one of the mandated benefits of "outpatient clinic services."

"This would change the status quo and offer direct taxpayer funding of abortion," said Tom McClusky, senior vice president of FRC Action. "We're not asking for a ban in private plans, but public taxpayer dollars should not be used for abortion."

The essential benefits standard would apply at first to public and private plans operating in a health insurance exchange and eventually would apply to employer-based coverage.

FRC is not disputing that health reform is needed, McClusky said, but the group's primary concern is to make sure the process "doesn't turn into a normalization of abortion."

Meanwhile, groups on the other side of the debate contend that anti-abortion organizations are using health system reform as a way to push for more prohibitions on abortion.

"Opponents of reproductive health care are trying to make you think that the public plan is a government-funded health plan like Medicaid or Medicare -- it is not," stated a July 24 memo from the Planned Parenthood Federation of America. "There is nothing currently in health care reform that expands abortion coverage. The majority of plans already cover basic reproductive health care, including abortion care."

The language describing the essential benefits package in the House bill is vague when it comes to the actual services that would be mandated, and plans would need to be certified by federal officials. Some health care policy organizations said a framework already exists within the government benefits structure that would serve as a good model for defining the package.

A report released July 22 by the American Cancer Society Cancer Action Network and the Georgetown University Health Policy Institute found that the Federal Employees Health Benefits Plan offers a Blue Cross Blue Shield standard option that demonstrates what a minimum essential benefits package should be.

Georgetown researchers evaluated that plan's coverage for stage II breast cancer, stage III colon cancer, heart attack and type I diabetes. They concluded that the benefits are comprehensive and that cost-sharing for routine care is modest.

"It is very good coverage," said Stephen Finan, senior director of policy for ACS CAN. "It's not Cadillac coverage, but it does a good job of covering all the essential services that are needed for these four serious medical conditions."

What the bill would do

The House bill, America's Affordable Health Choices Act, first would establish the essential benefits package within a national health insurance exchange, a feature of the proposal that would allow individuals and businesses to compare a public plan option with private coverage.

Plans would fall into four benefit categories -- basic, enhanced, premium and premium plus -- depending on the levels of cost-sharing and benefits. Premium plus, for example, would provide adult dental and vision care coverage. Plans that offer more generous coverage would need to offer at least the basic benefits.

The bill also would create a public-private, independent advisory panel, made up of government representatives, medical professionals and other health care experts, that would be chaired by the U.S. surgeon general. The Health Benefits Advisory Committee would recommend initial benefit standards to the Health and Human Services secretary within one year of the bill's enactment.

But private health insurers said the bill should be altered to provide more flexibility to plans.

In recent testimony provided to the House Energy and Commerce Committee, Karen Ignagni, president and CEO of America's Health Insurance Plans, said her group supports the creation of an essential benefits plan. But, rather than designating an advisory committee to specify what makes up these essential benefits, the bill simply should establish basic categories of coverage and actuarial value ranges that plans must meet.

Then, Ignagni said, insurance companies could craft individual health plan products that would adhere to those desired levels of benefits and cost-sharing. This would better allow insurers the opportunity to offer enhancements, such as wellness programs, additional preventive care and disease management programs, she said.

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What every health plan should cover

The House health system reform bill includes an "essential benefits package" that lays out what even the most basic public or private health plan eventually must offer. The broad categories are:

  • Hospitalization
  • Outpatient hospital and clinic services, including emergency department services
  • Physician and other health professional services
  • Incidental services, equipment and supplies
  • Prescription drugs
  • Rehabilitative and habilitative services
  • Mental health and substance use disorder services
  • Preventive services
  • Maternity care
  • Well-baby and well-child care -- including oral, health, vision and hearing services, equipment and supplies for children younger than 21
  • Durable medical equipment, prosthetics, orthotics and related supplies

Source: America's Affordable Health Choices Act of 2009

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