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Essential Health Benefits
Health and Human Services (HHS) report to Congress and the public.1 Section 1302 of the ACA requires that the report contain
• An assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;
• An assessment of whether the EHB need to be modified or updated to account for changes in medical evidence or scientific advancement;
• Information on how the EHB will be modified to address any such gaps in access or changes in the evidence base; and
• An assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations.2
In Chapter 7, the committee recommends developing a framework to guide the data collection and research infrastructure necessary to identify problems with access and advances in science (the first two required elements of the report to Congress). The information developed through this recommendation provides the starting point for the process of updating the EHB. In this chapter, the committee recommends an approach to updating the EHB, using criteria discussed earlier. The committee also recommends an approach to incorporating costs into the update process (responding to the fourth bullet in the report to Congress).
In its deliberations, the committee recognized that Congress intended the EHB to be similar in structure to existing employer benefit packages. However, the committee believes that over time, the Secretary will have an opportunity to provide leadership through the EHB updating process to improve the content and structure of the EHB to better reflect the scientific evidence base, to reflect societal priorities in providing a basic set of benefits, to ensure greater clarity about what services are and are not eligible for coverage in those policies covered by the EHB definition, and to promote high-value utilization.
Evidence-Based Science Should Be the Guiding Force
The committee concluded that the scope of benefits eligible for coverage should be guided by scientific evidence about which screening, diagnosis, treatment, management, and monitoring interventions are effective in improving or maintaining people’s health and functioning. For example, physician specialty societies, independent research organizations, health plans, and other organizations that focus on particular health problems increasingly incorporate the results of scientific studies into their treatment and payment guidelines. The Institute of Medicine (IOM) has recently released reports on strengthening standards for developing trustworthy clinical guidelines and systematic reviews, and the committee believes that these standards should inform the way medical evidence is used to shape future iterations of the EHB (IOM, 2011a,b). This means that the EHB would make eligible for coverage those interventions that are effective and would not make eligible for coverage those aspects of care that have not been shown to be effective. In Chapters 2 and 3, the committee discusses application of hierarchies of evidence in defining the scope of benefit inclusions and the need to strengthen medical practice to be more evidence-based.
Greater Specificity Required in Defining the EHB
If the EHB are to be guided by scientific evidence in the future, the definitions and descriptions of what is included and excluded must become more specific, consistent with the way scientific evidence is structured. There
1 Patient Protection and Affordable Care Act of 2010 as amended. § 1302(b)(4)(H), 111th Cong., 2d sess.