What benefits are essential to health insurance coverage? That's the mammoth question facing the Department of Health and Human Services these days as it prepares to define Essential Health Benefits for the insurance plans offered through state purchasing exchanges. Broadly speaking, the so-called EHBs come out of an Affordable Care Act requirement that insurers offer packages that include 10 categories of care, which range from emergency services and hospitalization costs to preventive and wellness services.


And an Institute of Medicine report released last week, while avoiding the details of which specific benefits should be in or out, recommends that HHS walk a tightrope between the twin goals of opening up access to quality care and keeping said care within the budgets of employers and workers.

Framing the issue around the challenge of building a package that both meets Americans' health needs while remaining affordable to the smaller businesses and their workers, who are expected to use the exchanges, the report's brief compares the challenge with that of a weekly trip to the grocery store.

"One option is … to fill up your cart with the groceries you want, and then find out what it costs," the brief states. "The other option is to … fill the cart carefully, with only enough food to fit in your budget. The committee recommends that HHS take the latter approach."

So what does a budget-minded health insurance plan look like? The IOM again avoided specifics, but suggested that HHS create a broad framework that:

  • Considers the population's health needs as a whole.
  • Encourages better care by ensuring good science is used to inform practice decisions.
  • Emphasizes the judicious use of resources.
  • Carefully uses the economic tools to improve value and performance.

Lofty goals all; and of course, balancing population health needs with the judicious use of resources will be where the rubber meets the road, as it always does. 

"Unless we are able to balance the cost with the breadth of benefits covered in the EHB, we may never achieve the health care coverage envisioned in the ACA," the report notes. "If benefits are not affordable, fewer individuals will buy insurance. If accessing benefits is too difficult, people will not get the care they need."

Given both the health care and financial ramifications of how these benefits play out over time, this may be one of the most important questions facing the industry right now. So what benefits do you think are essential to health insurance? Email your thoughts to hbush@healthforum.com.