The committee finds that no single policy lens is sufficient or comprehensive enough for explicitly framing decisions about the EHB. Figure 3-1 graphically illustrates the four domains and principles associated with those domains. Each of these distinct perspectives—complementary in some cases, overlapping in others, conflicting at times—influences how we think about what health insurance should cover and how it should be implemented.


A benefit design framework rooted in economics primarily conceives of coverage as insurance— protecting individuals and their families against the risk of unforeseen health care needs, particularly those associated with large expenses (Santerre and Neun, 2010). An economics approach uses markets to promote value and efficiency, relying heavily on these markets to find the equilibrium between price and demand. With respect to the ACA, new markets are being developed for health insurance products that will include the EHB. Decisions about the scope of coverage in the EHB package and product benefit design will affect its success in the market—both whether it can be sustained with private and public funds over time and whether a sufficient number of insurers will participate in the exchange, or otherwise opt to exclusively sell plans not subject to the EHB (e.g., those with a grandfathered status, or self-insured in the large employer market). Insufficient participation of willing purchasers or willing suppliers of insurance products may affect competitiveness as well as require government intervention in the content of packages offered or their price. Ideally, insurers will compete for the estimated 68 million EHB-related purchasers and will do so in a way that provides multiple insurance options at competitive prices.


FIGURE 3-1 Four policy domains with associated foundational principles for thinking about essential health benefits development and implementation.

NOTE: EBP = evidence-based practice.

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