Defining Essential Health Benefits

(September 2, 2011)  The Institute of Medicine (IOM) will soon produce a report outlining recommendations on the criteria and methods that the Department of Health and Human Services (HHS) could use when defining and updating “essential health benefits” for health plan options under the insurance exchanges created by the Affordable Care Act (ACA).  The findings are the result of a one-year study, initiated at the request of HHS Secretary Kathleen Sebelius and conducted by an IOM staff and advisory committee.

The insurance exchanges will offer consumers a variety of qualified health plans that vary in coverage levels but meet certain standards in categories of care, including preventive and wellness services and chronic disease management. And while all eyes are watching first what the IOM will recommend and then what HHS does with those recommendations, it’s promising that coverage for preventive health benefits will be part of ”essential benefits” as a specific category for inclusion under the ACA.

Chronic diseases, such as asthma, cancer, diabetes and heart disease, are the leading causes of death, disability, and rising healthcare costs in the U.S., and are an increasing burden on our healthcare system, public budgets, and economy at large.  Chronic disease costs consume more than 90 cents of every dollar spent on Medicare and Medicaid.  In sharp contrast, we spend less than 5 cents on prevention.

The encouraging news is that the vast majority of chronic disease cases are largely avoidable and highly manageable. The way to achieve any progress in the fight against chronic diseases is with appropriate measures to set-up and support long-term prevention and care coordination solutions.

With preventive health benefits as a standard, or “essential” benefit, we ensure more of us have the access to care we need to help identify, diagnose and, possibly stave off, chronic disease conditions before they become more serious and more costly. 

On behalf of the Partnership to Fight Chronic Disease, I commend the IOM staff and committee for their commitment and leadership in analyzing both the current state of prevention and wellness care and in offering thoughtful insight as we move forward in developing more effective approaches to prevent and manage chronic diseases.  Their recommendations to HHS could help set the stage for the progress we hope to achieve in preventing the debilitating and costly chronic diseases that have claimed more than 1,126,610 people in America so far this year.