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Essential Health Benefits: Balancing Affordability and Adequacy

This article discusses the importance of balancing affordability and adequacy in essential health benefits, focusing on market-based competition and the principles of economics, ethics, and evidence-based practice. It explores the need for clear benefit language, limits and exclusions, and understandable pricing to ensure affordability. Key decisions and considerations are examined, along with the role of metrics in expressing benefit value and cost impact.

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Essential Health Benefits: Balancing Affordability and Adequacy

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  1. Essential Health Benefits: Balancing Affordability and Adequacy John Santa MD MPH Director, Health Ratings Center Consumer Reports February 3, 2012

  2. R 12. Consumer Reports employee A T E R

  3. Systems are perfectly designed to get the results they achieve.

  4. Key Decisions Already Made • Should health insurance be market based? • If market based should we enable/encourage competition? • Should that competition include price/cost?

  5. IOM Essential Health BenefitsPrinciples for Proceeding • Economics • Ethics • Evidence based practice • Population health

  6. Functional Competition • Level playing field • What is promised---benefits • What it costs---premium, cost share • What is delivered---access, quality

  7. Benefits • Adequacy • Precise, understandable benefit language • Clear cut limits and exclusions • Understandable key definitions • Metric that expresses benefit value • Affordability • Precise, understandable price language • Metric that expresses impact of cost sharing

  8. “When you’re through learning, you’re through.” John Wooden Former UCLA basketball coach

  9. John Santa MD MPHConsumer Reports HealthDirector, Health Ratings Centersantjo@consumer.org914-378-2455

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