ACA Title 1, Sec. 1302. Essential health benefits requirements: “Bad”- Too comprehensive and wasteful. This provision establishes the set of benefits and maximum out-of-pocket (MOOP) cost sharing limits that will now apply across all qualifying insured plans. It includes a broad range of benefits by category and on the good side includes a new provision for all health plans providing “Essential Health Benefit Package” to provide a “Preventive and wellness services and chronic disease management” component. (Yea!) However, the bad thing is that the combination of the fairly comprehensive set of benefit coverage requirements and the MOOP limits (Bronze, Silver, Gold, Platinum) work to make all qualifying health plans very expensive thus putting a significant financial pressure on insurers and payers. Specially, when we are attempting to provide new insurance coverage to some 35 million people it adds costs that are excessive and strain the whole system. I believe that this represents a real case of over-reach and jeopardizes the whole effort. I would opt for a three tiered set of benefits with a truly “basic” benefit level, a “medium” level and a “high” level with the individual and business mandates applying only to the “basic” level. On the good side this section includes a limitation on the size of deductibles at $2,000 for individual plan coverage and $4,000 for family coverage. This makes sense but needs to be linked to the personal health savings account provision funded with tax advantaged dollars to the consumer. Another provision of this section is that it prohibits cost sharing on preventive services which is a good feature. Finally, the “wasteful” nature of this provision comes from the fact that our most rigorous research shows that comprehensive health insurance coverage is generally not associated with significant improvement in health status, we may feel better with a richer health insurance plan, but we will not be appreciably healthier. Thus the “wasteful” label on these more comprehensive than needed benefit requirements.

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