Providing Cover
Federal officials are busily trying to determine what basic health care plans should cover, and there is no shortage of services being pushed.

By Meghan McCarthy
National Journal, Wednesday, May 18, 2011

Should basic pediatric care be fully covered by every health plan? How about plastic surgery? Should children with autism be guaranteed speech therapy?

While budget negotiations on Capitol Hill and in the White House have focused on how to bring down Medicare and Medicaid costs, federal officials are taking on one of their toughest tasks under the health law, and it could have broad implications for nationwide health spending.

The year-old health law requires insurance plans to meet a minimum of coverage before they may participate on the state-based insurance exchanges that open in 2014. The statute already lays out service categories that must be included in qualified plans, including doctor visits, emergency services and hospital stays, and prescription drug coverage.

But the devil here is in the details, and Health and Human Services is tasked with figuring out exactly what insurance plans should cover, ensuring they are comprehensive without costing too much. It’s a job that’s never been done by the insurance industry, as the law aims to give millions of people better insurance than they have now.

HHS must define exactly what treatments get covered within the categories laid out in the law. The regulation is expected by the end of the year, and HHS has built in some political cover by contracting with the Institute of Medicine to develop a methodology that can be used to figure out exactly how to make the cuts.

Disease and patient advocacy groups are doing their best to lobby Capitol Hill and in the hallways of HHS and the IOM to get their specific treatments included in the qualified plan.

Each group has a compelling story, and each will be a tough call for HHS. The American Academy of Pediatrics wants children to get the dental and vision care they need, and not be capped at a certain number of visits per year. Care for kids is cheaper than treating sick adults in the long-run, says AAP.

The National Coalition for Cancer Survivorship wants cancer to be defined as a chronic condition, and wants plans to pay for coordination among a patient’s various treatments. They also urge coverage for off-label cancer drugs.

The American Chiropractic Association urged the government to cover more outpatient, walk-in services, rather than “invasive, high-risk” inpatient procedures. The American Society of Plastic Surgeons wants office-based procedures covered.

Jeff Sell, vice president of the Autism Society, wants the plans to cover “habilitative” care, or treatments that help improve a patient’s quality of life. For autism treatments, habilitative care might be speech therapy that helps a patient learn to talk.

In the past, insurance companies have not covered habilitative care, but they do cover rehabilitation, which helps a patient get back to their normal lives.

Habilitative services is one of the categories of care listed in the health law, but it is grouped with rehabilitation. Patient groups worry that might mean it gets dropped in favor of rehabilitative services.

“It helps kids acquire skills they didn’t have before, but they have routinely been denied,” Sell said. He opposes dropping habilitative care from the basic “bronze” exchange plans, but including it on the more expensive “silver”, “gold,” or “platinum” plans.

“We’re not talking about an upgrade here; we’re talking about basic care.” Sell says habilitative care means children with autism are less likely to end up institutionalized.

Despite the drive to include everything they can, some disease groups are aware of the balance the plans must strike with affordability.

The National Health Council, an umbrella organization of more than 100 health organizations that represents people with chronic diseases and disabilities, checked whether a typical Blue Cross Blue Shield plan offered to federal employees could be affordable to people making under 400 percent of the federal poverty line, or $43,000. That is the cutoff for receiving government subsidies on the insurance exchange.

The research showed that a robust plan like those offered to federal employees may not be affordable, especially to people making under $40,000 a year, said Marc Boutin, executive vice president at the Council. Federal employee plans have been floated as a possible template for required coverage under the health law.

“We’ve had some concerns, based on that analysis,” Boutin said. “I don’t think it will be based off the Federal Employee Health Benefits Package. It’s clear we might see something less robust.”

Health economist Jon Gruber, who helped design the Massachusetts health reform effort, agrees.

“HHS has to take a pretty hard line on this,” Gruber said, to find a successful balance between affordable and comprehensive coverage.

“Once you open that door, the lots of little things start adding up to significant dollars,” Gruber said. He believes HHS must stick with what the law lays out, and not add lots of additional services.

While disease groups might argue that treatments for their particular disease save dollars in the long-run, Gruber said there is usually not enough evidence to support those claims.

“The burden of proof is pretty high on disease groups,” Gruber said. “But there is almost never valid empirical evidence. “

In the current political and fiscal environment, the agency will likely have to err on the side of less instead of more.