Although the committee focuses here on the monitoring and research needs relevant to the EHB, it recognizes that the optimal strategy within HHS is likely to be a coordinated approach across all areas. With respect to the EHB, monitoring and research can
• Provide input into the process of updating the EHB,
• Contribute to addressing questions in the Section 1302(b)(4)(G) required reports to Congress and the public,
• Monitor for discriminatory practices and balance as a result of initial EHB definition and its implementation, and
• Assess the impact of the EHB on consumers, employers, health care providers, insurers, and governments at the state and local levels.
Congress, in Section 1302 of the ACA in particular, calls out an interest in any problems related to access, methods for incorporating evidence of medical advances into the EHB, ideas about how best to close any gaps observed in access or changes to evidence, and assessing the cost implications of potential changes to the EHB. The committee also believes that HHS will want to know whether initial guidance on the EHB is achieving an appropriate balance between cost and coverage; how specific design elements and medical necessity determination processes can affect care delivered, outcomes, and value; whether rates of participation by consumers, employers, and insurers are affected by the EHB; how the EHB package can be updated to become more evidence-based and value-promoting; and what impact the composition of exchange participation has on premiums (e.g., greater or lesser participation by employers and individuals).
The committee believes the monitoring and research strategy related to the EHB should be articulated thoughtfully as soon as possible to enhance planning efforts, allocate necessary resources, and align priorities for collecting comparable data among different stakeholders. A systematic pursuit of this strategy is consistent with creating a learning health care system (IOM, 2007, 2011). Such a strategy should engage stakeholders in ensuring that the right questions are being asked, that the purposes for the collected data are clear, that modifications to the EHB are justified and fair, that the EHB are becoming increasingly evidence-based over time, and that the country is spending its tax dollars (and enrollees their premium dollars) effectively and efficiently.
State oversight is important during approval of plan offerings, implementation, and appeals. The state and federal health insurance exchanges are responsible for determining which health plans are qualified to operate in the exchange and can serve as a primary data source for what is happening across states and over time in response to the Secretary’s guidance. The EHB are also required for incorporation in all non-grandfathered individual and small employer policies offered outside the exchange; such plan oversight would be outside of exchange operations, but under the aegis of state insurance commissioners. Thus, oversight responsibility cannot lay solely with exchanges. Ideally, state departments of insurance will actively take on the responsibility to protect against adverse selection and discriminatory practices in their jurisdiction; it important that health plans, in and out of the exchanges, are complying with requirements of the EHB package and not using benefit design and administration to risk-select or deny access to care. Additionally, the EHB are to be incorporated in new Medicaid benchmark, benchmark-equivalent, and state basic health insurance instruments; these will be under a separate state agency, also reporting to Centers for Medicare & Medicaid Services (CMS).
Leveraging these potential state-level data resources will require providing clarity and standardization in data collection (e.g., categorization of included benefits; descriptions of plan limits, types of treatments and conditions that are the subject of appeals), which will in turn improve opportunities for the analysis of comparative data. State collection and reporting of data can be a condition of states receiving federal funding to establish the exchanges; notably though, federal funding of state exchanges is time limited. Insurer reporting of plan content, however, will remain a condition of being certified a qualified health plan. This information will also provide insight beyond the exchange because of the requirement for insurers to offer the same plans outside as inside. Insurers will likely be