ESSENTIAL HEALTH BENEFITS
BALANCING COVERAGE AND COST

Cheryl Ulmer, John Ball, Elizabeth McGlynn, and Shadia Bel Hamdounia, Editors
Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans
Board on Health Care Services

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL PRESS
Washington D.C.
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EssEntial HEaltH BEnEfits Balancing Coverage and Cost Cheryl Ulmer, John Ball, Elizabeth McGlynn, and Shadia Bel Hamdounia, Editors Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans Board on Health Care Services

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This study was supported by Contract No. HHSP 23320042509XI, Task Order HHSP23337027T between the National Academy of Sciences and the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21914-3 International Standard Book Number-10: 0-309-21914-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Wash - ington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Essential Health Benefits: Balancing Coverage and Cost. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in sci - entific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad com - munity of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the gov - ernment, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON DEFINING AND REVISING AN ESSENTIAL HEALTH BENEFITS PACKAGE FOR QUALIFIED HEALTH PLANS JOHN R. BALL (Chair), Former Executive Vice President, American Society for Clinical Pathology MICHAEL S. ABROE, Principal and Consulting Actuary, Milliman, Inc. MICHAEL E. CHERNEW, Professor of Health Care Policy, Harvard Medical School PAUL FRONSTIN, Director, Health Research & Education Program, Employee Benefit Research Institute ROBERT S. GALVIN, Chief Executive Officer, Equity Healthcare, Blackstone Group MARJORIE GINSBURG, Executive Director, Center for Healthcare Decisions DAVID S. GUZICK, Senior Vice President for Health Affairs, and President, UF&Shands Health System, Univer- sity of Florida SAM HO, Executive Vice President and Chief Medical Officer, UnitedHealthcare CHRISTOPHER F. KOLLER, Health Insurance Commissioner, State of Rhode Island ELIZABETH A. McGLYNN, Director, Kaiser Permanente Center for Effectiveness & Safety Research AMY B. MONAHAN, Associate Professor, University of Minnesota Law School ALAN R. NELSON, Internist-Endocrinologist LINDA RANDOLPH, President and Chief Executive Officer, Developing Families Center JAMES SABIN, Clinical Professor, Departments of Psychiatry and Population Health, Harvard Medical School, and Director, Harvard Pilgrim Health Care Ethics Program JOHN SANTA, Director of Consumer Reports Health Ratings Center, Consumer Reports LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California JOE V. SELBY, Executive Director, Patient-Centered Outcomes Research Institute SANDEEP WADHWA, Chief Medical Officer and Vice President of Reimbursement and Payer Markets, 3M Health Information Systems Study Staff CHERYL ULMER, Study Director SHADIA BEL HAMDOUNIA, Research Associate CASSANDRA L. CACACE, Research Assistant ASHLEY McWILLIAMS, Senior Program Assistant (through July 2011) ROGER C. HERDMAN, Director, Board on Health Care Services v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Linda Burnes Bolton, Cedars-Sinai Medical Center Troyen Brennan, CVS Caremark Jon Gabel, National Opinion Research Center, University of Chicago Neal Gooch, Utah Insurance Department Jonathan H. Gruber, Massachusetts Institute of Technology Gail Gibson Hunt, National Alliance for Caregiving Michael M. E. Johns, Emory University Timothy S. Jost, Washington and Lee University School of Law Robert Krughoff, Center for the Study of Services Eric Larson, Group Health Research Institute Jerry Elizabeth Malooley, Benefit Programs and Health Policy for the State of Indiana Wendy K. Mariner, Boston University School of Public Health Debra L. Ness, National Partnership for Women and Families Peter Neumann, Tufts University School of Medicine Sara Rosenbaum, The George Washington University School of Public Health and Health Services Alice Rosenblatt, AFR Consulting, LLC Joshua M. Sharfstein, Department of Health and Mental Hygiene, State of Maryland Gail Wilensky, Project HOPE Matthew Wynia, American Medical Association vii

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viii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Christine K. Cassel, American Board of Internal Medicine and Donald M. Steinwachs, Johns Hopkins University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Foreword The Patient Protection and Affordable Care Act marks a milestone on a path toward substantially reducing the number of uninsured and underinsured individuals in this nation. The lack of health insurance is harmful to health, and equity in access to needed health care is one measure of a just society. But in creating the conditions for expanded insurance coverage, how, exactly, should one go about deciding what to include as essential in a health insurance plan? This Institute of Medicine report Essential Health Benefits: Balancing Coverage and Cost answers this ques- tion. The Patient Protection and Affordable Care Act sets out parameters and guidance that serve as a point of departure and a constant reference for the committee’s deliberations. This report lays out criteria and methods to define and update the essential health benefits package. The committee’s recommendations aim at promoting evidence-based practices and prudent stewardship of resources. They encourage innovation and suggest ways to remain sensitive over time to evolving public preferences for coverage. This study was initiated at the request of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services, and we sincerely hope the report will prove useful in the implementation of broader insurance coverage. I am grateful for the support of our sponsors and to the committee, led by John Ball, which grappled with the complexity of balancing coverage needs of individuals and the sustainability of the essential health benefits package. Their work was reinforced by staff working under the direction of Cheryl Ulmer and including Shadia Bel Hamdounia, Cassandra Cacace, and Ashley McWilliams. I commend both committee and staff for this product and believe it provides a sound basis for the defining, and future refining, of an essential health benefits package. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine July 2011 ix

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Preface A critical element of the Patient Protection and Affordable Care Act (ACA) is the set of health benefits—termed “essential health benefits” (EHB)—that must be offered to individuals and small groups in state-based purchasing exchanges and the existing market. If the package of benefits is too narrow, health insurance might be meaningless; if it is too broad, insurance might become too expensive. The Institute of Medicine (IOM) Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans concluded that the major task of the Secretary of the Department of Health and Human Services (HHS) in defining the EHB will be balancing the comprehensiveness of benefits with their cost. Not surprisingly, the work of this committee drew intense public interest. Opportunity for public input was offered through testimony at two public hearings and through the Web. The presentations at the hearings reinforced for the committee the difficulty of the task of balancing comprehensiveness and affordability. On the one hand, groups representing providers and consumers urged the broadest possible coverage of services. On the other, groups representing both small and large businesses argued for affordability and flexibility. The committee thus viewed its principal task as helping the Secretary navigate these competing goals and preferences in a fair and implementable way. The ACA sets forth only broad guidance in defining essential health benefits, and that guidance is ambigu - ous—some would say contradictory. First, the EHB “shall include at least” 10 named categories of health services per Section 1302. Second, the scope of the EHB shall be “equal to the scope of benefits provided under a typical employer plan.” Third, there are a set of “required elements for consideration” in establishing the EHB, such as balance and nondiscrimination. Fourth, there are several specific requirements regarding cost sharing, preventive services, proscriptions on limitations on coverage, and the like. Taken together, these provisions complicate the task of designing an EHB package that will be affordable for its principal intended purchasers—individuals and small businesses. The committee’s solution is this: build on what currently exists, learn over time, and make it better. That is, the initial EHB package should be a modification of what small employers are currently offering. All stakehold - ers should then learn enough over time—during implementation and through experimentation and research—to improve the package. The EHB package should be continuously improved and increasingly specific, with the goal that it is based on evidence of what improves health and that it promotes the appropriate use of limited resources. The committee’s recommended modifications to the current small employer benefit package are (1) to take into account the 10 general categories of the ACA; (2) to apply committee-developed criteria to guide aggregate and xi

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Acknowledgments The committee and staff are grateful for many individuals and organizations who contributed to the success of the report. Many thanks go to the numerous individuals to whom staff spoke before and during the study process, as well as those who submitted responses to the committee’s online comment form and other materials. In addition, the committee wants to thank those who testified before it during the two public workshops: Jessica Banthin, Agency for Healthcare Research and Quality Carmella Bocchino, America’s Health Insurance Plans Meg Booth, Children’s Dental Health Project David Bowen, The Bill & Melinda Gates Foundation Virginia Calega, BlueCross BlueShield Association Arnold Cohen, American Congress of Obstetricians and Gynecologists Rex Cowdry, Maryland Health Care Commission Helen Darling, National Business Group on Health Jina Dhillon, National Health Law Program James Dunnigan, Utah State House of Representatives Cindy Ehnes, California Department of Managed Health Care John Falardeau, American Chiropractic Association Linda Fishman, American Hospital Association Marty Ford, The Arc and United Cerebral Palsy Disability Policy Coalition Jean Fraser, San Mateo County Health System Brian Gallagher, American Pharmacists Association Alan Garber, Stanford University Center for Health Policy Andrew George, California Department of Managed Health Care Jonathan Gruber, Massachusetts Institute of Technology and the National Bureau of Economic Research Gerald Harmon, American Medical Association Mark Hayes, Greenberg Taurig, LLP Leah Hole-Curry, Washington State Health Technology Assessment Program Carolyn Ingram, Center for Health Care Strategies Louis Jacques, Centers for Medicare & Medicaid Services xv

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xvi ACKNOWLEDGMENTS Jeffrey Kang, CIGNA Corporation Jon Kingsdale, Wakely Consulting Sharon Levine, The Permanente Medical Group Jerry Malooley, U.S. Chamber of Commerce Robert McDonough, Aetna Maureen McKennan, California Department of Managed Health Care Sean Morrison, National Palliative Care Research Center Robert Murphy, American Society of Plastic Surgeons Samuel Nussbaum, WellPoint Kavita Patel, University of California, Los Angeles (UCLA) Semel Institute Susan Philip, California Health Benefits Review Program Joseph Piacentini, Employee Benefits Security Administration, Department of Labor (DOL) Andrew Racine, American Academy of Pediatrics Sara Rosenbaum, George Washington University School of Public Health and Health Services Somnath Saha, Portland VA Medical Center and Oregon Health Services Commission Matthew Salo, The National Governors Association Beth Sammis, Maryland Insurance Administration Paul Samuels, Legal Action Center and Coalition for Whole Health Cathy Schoen, The Commonwealth Fund David Schwartz, Senate Finance Committee Thomas Sellers, National Coalition for Cancer Survivorship Jeanene Smith, Office of Oregon Health Policy and Research Richard Smith, Pharmaceutical Research and Manufacturers of America Katy Spangler, U.S. Senate Committee on Health, Education, Labor, and Pensions Stuart Spielman, Autism Speaks Peter Thomas, Consortium for Citizens with Disabilities Jeffery Thompson, Washington State Department of Social and Health Services Michael Turpin, USI Insurance Services Gary Ulicny, The Shepherd Center Barbara Warren, Consumers United for Evidence-Based Healthcare Kenneth B. Wells, David Geffen School of Medicine, UCLA William Wiatrowski, Bureau of Labor Statistics, DOL Bruce Wolfe, Obesity Action Coalition Anthony Wright, Health Access California Troy Zimmerman, National Kidney Foundation Funding for this study was provided by the Assistant Secretary for Planning and Evaluation (ASPE). The committee appreciates ASPE’s support for this project and would like to especially thank Sherry Glied, Richard Kronick, Caroline Taplin, Lee Wilson, and Pierre Yong for their expertise and guidance on the project. Lastly, many individuals within the Institute of Medicine were helpful throughout the study process, includ- ing Clyde Behney, Daniel Bethea, Patrick Burke, Marton Cavani, Greta Gorman, Laura Harbold, Abbey Meltzer, Elisabeth Reese, Vilija Teel, Stephanie Tioseco, and Lauren Tobias. We would also like to thank Florence Poillon for assisting in copyediting this report. Christine Stencel of the National Academies’ Office of News and Public Information provided substantial support in preparing for the public release of this consensus report and its com- panion workshop report; Rachel Marcus of the National Academies Press helped facilitate the publication of both manuscripts.

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Contents ABSTRACT 1 SUMMARY 3 1 INTRODUCTION 13 Committee Charge, 14 Major Issues, 15 Status of Current Health Insurance Coverage, 16 Impact of the EHB Across Insurance Programs, 18 Stakeholder Decisions Will Reshape Health Insurance Markets, 21 Organization of the Report, 22 References, 23 2 APPROACHES TO DETERMINING COVERED BENEFITS AND BENEFIT DESIGN 25 Understanding Terms, 25 Understanding Contributors to Costs, 32 Illustrative Approaches to Coverage Decisions, 35 References, 44 3 POLICY FOUNDATIONS AND CRITERIA FOR THE EHB 47 Policy Foundations, 48 Criteria, 54 References, 57 xvii

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xviii CONTENTS 4 RESOLVING ACA INTENT 59 Finding the Meaning of Essential, 60 10 Categories of Care vs. Typical, 61 Essential vs. Nonessential, 63 Boundaries or Not, 63 Understanding Typical Specificity in Scope of Benefits, 64 Typical Employer: Small vs. Large, 65 State Mandates, 71 Medical vs. Nonmedical, 74 References, 75 5 DEFINING THE EHB 79 Step 1: Develop the Starting Point, 80 Step 2: Incorporate Cost into the Development of the Initial EHB, 82 Step 3: Reconcile Initial List to the Premium Target, 87 Step 4: Issue Guidance on Inclusions and Permissible Exclusions, 87 Committee Recommendation on Defining the EHB, 90 Other Areas for the Secretarial Guidance Related to the EHB, 91 References, 100 6 PUBLIC DELIBERATION 103 The Public Voice, 103 Components of Public Deliberation Processes, 107 Examples of Public Participation and Deliberative Processes, 110 Summary of Guidelines for Public Participation, 112 References, 113 7 PROGRAM MONITORING AND RESEARCH 115 Setting a Research Framework for Data Collection and Analysis, 116 Program Monitoring and Research, 118 Broad Areas of Research, 123 References, 126 ALLOWANCE FOR STATE INNOVATION 129 8 Authority for State Variation, 129 Flexibility in Determining the EHB, 130 Criteria for Approving a State-Specific EHB Definition, 131 Political Implications, 132 References, 132 9 UPDATING THE EHB 135 ACA Direction to the Secretary on Updating the EHB, 135 Goals for Updating, 136 Considering Typical Employer in the Future, 138 Methods for Incorporating Costs into Updates to the EHB, 138 Consequences for the EHB and ACA of Failing to Address Rising Health Care Costs, 142 National Benefits Advisory Council, 145 Conclusion, 149 References, 150

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xix CONTENTS APPENDIXES A Patient Protection and Affordable Care Act, Section 1302, and Web Questions for Public Input 153 B Stakeholder Decisions on Health Insurance 159 C Examples of Possible Degrees of Specificity of Inclusions in Small Group and Individual Markets 169 D Examples of Benefit Package Statutory Guidance 191 E Description of Small Group Market Benefits, Provided by WellPoint 197 F General Exclusions 209 G Medical Necessity 225

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Boxes, Figures, and Tables Summary Box S-1 Essential Benefits Categories in the Patient Protection and Affordable Care Act, 6 Figures S-1 Four policy domains with associated foundational principles for thinking about essential health benefits development and implementation, 4 S-2 Criteria for assessing content of essential health benefits (EHB) in the aggregate, for specific components, and for methods, 5 Chapter 1 Boxes 1-1 Statement of Task for the Institute of Medicine Committee, 14 1-2 Which Programs Incorporate Essential Health Benefits (EHB)?, 19 Figures 1-1 Nonelderly population with selected sources of health insurance coverage, 2009, 17 1-2 Different stakeholder considerations during implementation of the Patient Protection and Affordable Care Act (ACA), 21 1-3 Learning cycle for defining and revising essential health benefits (EHB), 22 Table 1-1 Transitions from Status Quo Insurance Status to Post-Reform Insurance Status, 18 xxi

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xxii BOXES, FIGURES, AND TABLES Chapter 2 Boxes 2-1 Understanding Basic Terms Used in This Chapter and Report, 26 2-2 Description of Benefit Design, 30 2-3 The BlueCross and BlueShield Association Technology Evaluation Center’s Clinical Coverage Criteria, 38 2-4 UnitedHealthcare’s Hierarchy of Criteria for Benefit or Coverage Determination, 38 2-5 Hierarchy of Evidence Employed by Washington State, 40 2-6 Oregon Treatment-Condition Pair Examples, 42 2-7 Inclusion Criteria for Oregon’s Value-Based Services (VBS), 43 Figures 2-1 Illustration of multiple medical management tools used by UnitedHealthcare, 32 2-2 Real spending on health care in selected categories, 1965-2005, 34 2-3 WellPoint, Inc. has various paths for reviewing benefit coverage to make medical policy decisions, 37 Tables 2-1 Estimated Contributions of Selected Factors to Growth in Real Health Care Spending per Capita, 1940 to 1990, 35 2-2 The State of Oregon Uses a Prioritized List of Services to Make Coverage Decisions, 42 Chapter 3 Box 3-1 The American Medical Association’s (AMA’s) Ethical Force Program Five Content Areas for Performance Measurement in Designing and Administering Health Benefits, 51 Figures 3-1 Four policy domains with associated foundational principles for thinking about essential health benefits development and implementation, 48 3-2 Criteria for assessing content of essential health benefits (EHB) as a whole and for specific components, 55 3-3 Criteria to guide methods for defining and updating the essential health benefits (EHB), 57 Table 3-1 Uses of Evidence for Decision Making, 53 Chapter 4 Figure 4-1 Comparison of UnitedHealthcare (UHC) Federal Employees Health Benefit (FEHB) program plan offered in Virginia (VA) vs. other UHC small business plans offered in the state, 70 Table 4-1 Percentage of Firms Offering Health Benefits, by Firm Size, 1999-2011, 66

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xxiii BOXES, FIGURES, AND TABLES Chapter 5 Boxes 5-1 Steps in Recommended Process for Defining an Essential Health Benefits (EHB) Package, 80 5-2 General Exclusions: Federal Employee Health Benefit Program Fee-for-Service Option, 89 5-3 Selected Required Elements for Consideration, 92 Tables 5-1 Congressional Budget Office (CBO) Estimates of the Effect of the Law on Premiums in the Small Group Market, in November 2009 Letter to Senator Bayh, 83 5-2 Congressional Budget Office (CBO) Estimates of the Effect of the Law on Premiums in the Individual Market, in November 2009 Letter to Senator Bayh, 84 5-3 Congressional Budget Office (CBO) Estimated Premiums for Individual and Family Policies in Exchange Markets, in Letter to Senator Bayh, Converted to 2014 Dollars, 84 5-4 Premiums for Single Coverage in the Exchange Market in the Absence of the Patient Protection and Affordable Care Act (ACA) Compared with After Implementation of the ACA (in 2014 dollars), 85 5-5 Individual and Small Group Premiums in Exchange Markets When Risk Pools Are Split or Combined (in 2014 dollars), 85 5-6 Sample Approach to Incorporating Costs into the Definition of Essential Health Benefits, 86 5-7 Key Elements in Definitions of Medical Necessity, 97 Chapter 6 Tables 6-1 Summary of Opportunities for Patient or Public Input in Selected Technology Coverage Processes in Different Regions, 105 6-2 CHAT Results from Medi-Cal Survey of Users’ Views (Adults with Disabilities) on Public Input in Areas of Budget Cut, 112 Chapter 7 Figures 7-1 CIGNA coverage decisions and appeals for preauthorization of health benefits (2010), 122 7-2 Health Technology Assessment (HTA) program coverage decisions vary between Washington (WA) state and private insurers, 124 Table 7-1 Comparison of 2010 Independent Medical Review (IMR) Results in California Managed Care, 121 Chapter 9 Tables 9-1 Illustrative Comparison of Current and Future Scope of Benefits for the Essential Health Benefits (EHB), 138 9-2 Existing Entities Considered by the Committee to Advise the Secretary on Updates to the Essential Health Benefits (EHB), 147 Figures 9-1 U.S. health care expenditure trends, 143 9-2 U.S. national health care spending relative to growth in gross domestic product (GDP), 143

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