• By January 1, 2013, advise the Secretary on a research plan and data requirements for updating the EHB package;
• Starting in 2015 for implementation in 2016, make recommendations annually to the Secretary regarding (1) any changes to the EHB package by applying the committee’s recommended criteria (see Figure S-2), (2) any changes to the premium target, and (3) any mechanisms that would enhance the evidence base of the EHB package and its potential for promoting value; and
• Advise the Secretary on conducting and using the results of a periodic national public deliberative process to inform its recommendations around updates to the EHB.
The ACA establishes an essential health benefits package and defines 10 general categories that must be included in that package. The ACA, however, left considerable discretion to the Secretary of HHS to design this package. The Secretary, in turn, asked the IOM to provide input on the process that might be undertaken to develop the EHB. In its deliberations, the most critical issue identified by the committee is the need to explicitly address the tradeoff between the cost of a benefit package and the comprehensiveness of coverage. If that tradeoff is not addressed, a number of consequences are possible:
• If the benefits are not affordable, fewer people will buy insurance.
• If the benefit design makes access too difficult, people will not get the care they need.
• If health care spending continues to rise faster than gross domestic product (GDP), the value of the EHB is likely to be eroded.
The committee concluded that the benefit package should be designed within the context of financial constraints, using a structured public process to establish priorities. The committee developed a set of criteria to guide the process for designing and updating the EHB. The EHB must be affordable, maximize the number of people with insurance, protect the most vulnerable individuals, protect against the greatest financial risks, promote better care, ensure stewardship of limited financial resources by focusing on high value services of proven effectiveness, promote shared responsibility for improving our health, and address the medical concerns of greatest importance to us all.
Eibner, C., F. Girosi, C. C. Price, A. Cordova, P. S. Hussey, A. Beckman, and E. A. McGlynn. 2010. Establishing state health insurance exchanges: Implications for health insurance enrollment, spending, and small businesses. Santa Monica, CA: RAND Corporation.
Glied, S. 2011. Testimony to the IOM Committee on the Determination of Essential Health Benefits by Sherry Glied, Assistant Secretary for Planning and Evaluation, HHS, Washington, DC, January 13.