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发帖数: 2273 | 1 By ROBERT PEAR
WASHINGTON — In a major surprise on the politically charged new health care
law, the Obama administration said Friday that it would not define a single
uniform set of “essential health benefits” that must be provided by
insurers for tens of millions of Americans. Instead, it will allow each
state to specify the benefits within broad categories.
The move would allow significant variations in benefits from state to state,
much like the current differences in state Medicaid programs and the
Children’s Health Insurance Program.
By giving states the discretion to specify essential benefits, the Obama
administration sought to deflect one of the most powerful arguments made by
Republican critics of President Obama’s health care overhaul — that it was
imposing a rigid, bureaucrat-controlled health system on Americans and
threatening the quality of care. Opponents say that the federal government
is forcing a one-size-fits-all standard for health insurance and usurping
state authority to regulate the industry.
This criticism has inspired legal challenges to the new law — with the
Supreme Court set to decide next year whether the government can require
Americans to buy health insurance — and helps explain why public opinion of
the law remains deeply divided.
The law is looming as a central issue in the 2012 presidential race, with
Republican presidential candidates being evaluated on the strength of their
opposition to it. The announcement by the administration follows its
decision this year to jettison a program created in the law to provide long-
term care insurance, a move that disappointed liberal backers of the program
championed by the late Senator Edward M. Kennedy.
The action Friday prompted questions among supporters of the new health care
law. Prof. Timothy S. Jost, an expert on health law at Washington and Lee
University, said, “The new bulletin perpetuates uncertainty about what
benefits an insurer will be required to cover under the Affordable Care Act.
” From the consumer’s point of view, Professor Jost added, “I wish the
Department of Health and Human Services had signaled that there would be
more uniformity and less flexibility.”
Chris Jacobs, a health policy analyst for Senate Republicans, said the new
policy “gives states the flexibility to impose more benefit mandates, not
fewer,” and would lead to higher insurance premiums, contrary to what Mr.
Obama promised in the 2008 campaign.
The new law lists 10 categories of “essential health benefits” that must
be provided by insurance offered in the individual and small-group markets,
starting in January 2014. These include preventive care, emergency services,
maternity care, hospital and doctors’ services, and prescription drugs.
Kathleen Sebelius, the secretary of health and human services, had been
expected to provide details of what services and benefits must be provided
in each category. Instead, in an insurance bulletin issued Friday, Ms.
Sebelius said the federal government would respect the states’ role, giving
them “the flexibility to design coverage options that meet their unique
needs.”
Under this approach, each state would designate an existing health insurance
plan as a benchmark. The benefits provided by that plan would be deemed
essential, and all insurers would have to provide benefits of the same or
greater value. Plans could modify coverage within a benefit category so long
as they did not reduce the value of coverage.
Each state would choose one of the following health insurance plans as a
benchmark:
¶ One of the three largest small-group plans in the state.
¶ One of the three largest health plans for state employees.
¶ One of the three largest national health insurance options for
federal employees.
¶ The largest health maintenance organization operating in the state’s
commercial insurance market.
While working on health care legislation in 2009 and 2010, Congress spent
many hours debating how to balance the goals of comprehensive benefits and
affordable coverage.
Sherry A. Glied, an assistant secretary of health and human services, said
the administration’s approach “builds off the experience of today’s
marketplace and will minimize disruption to it.”
Steven B. Larsen, deputy administrator of the federal Centers for Medicare
and Medicaid Services, said, “The state is always in control of what the
essential benefits package is in that state.”
In recent months, federal health officials have taken a number of steps that
could help inoculate Mr. Obama against charges that he was foisting a rigid
, inflexible model of health care on the nation.
Several states have received temporary waivers from tough new federal
standards that require insurers to spend more of each premium dollar for the
benefit of consumers. Federal officials have also provided temporary
exemptions from some provisions of the law for some employers and labor
unions offering bare-bones coverage.
The new law says that the scope of essential health benefits must be “equal
to the scope of benefits provided under a typical employer plan.” But the
law itself specifically requires some benefits not widely available in
employer-sponsored health plans, like “habilitative services” for people
with conditions like autism or cerebral palsy.
Under the new law, each state is supposed to have an insurance exchange or
marketplace where consumers can compare options and buy insurance. Health
plans must offer the essential benefits, regardless of whether the coverage
is sold inside or outside the exchange.
The government will offer subsidies to help low-income people buy insurance
through exchanges. The subsidies will help cover the cost of essential
benefits. States can require insurers to provide additional benefits, but
states will have to pay much of the extra cost.
The law also says that the definition of essential benefits must not “
discriminate against individuals because of their age, disability or
expected length of life.”
Sara Rosenbaum, a professor of health law and policy at George Washington
University, said the new bulletin “does not offer any guidance on this
crucial part of the law.” |
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