Essential Health Benefits: Balancing Affordability and Adequacy

John Santa MD MPHDirector, Health Ratings CenterConsumer ReportsFebruary 3, 2012

12. Consumer Reports employee

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Systems are perfectly designed to get the results they achieve.

Key Decisions Already Made

• Should health insurance be market based?

• If market based should we enable/encourage competition?

• Should that competition include price/cost?

IOM Essential Health BenefitsPrinciples for Proceeding

• Economics• Ethics• Evidence based practice• Population health

Functional Competition

• Level playing field– What is promised---benefits– What it costs---premium, cost share– What is delivered---access, quality

Benefits

• Adequacy– Precise, understandable benefit language– Clear cut limits and exclusions– Understandable key definitions– Metric that expresses benefit value

• Affordability– Precise, understandable price language– Metric that expresses impact of cost sharing

“When you’re through learning, you’re through.”

John WoodenFormer UCLA basketball coach

John Santa MD MPHConsumer Reports Health

Director, Health Ratings Centersantjo@consumer.org

914-378-2455