Excluded Benefits Lists Spark Debate

President Obama's hallmark domestic policy initiative has been blunting the worst shortcomings of the US healthcare system. But it is unrealistic to expect the PPACA alone to totally transform the practice and financing of medicine.

"Every revolution evaporates and leaves behind only the slime of a new bureaucracy." – Franz Kafka

After receiving a recent HealthPocket.com study on the Top 10 medical services excluded from health insurance policies on the new public exchanges, my first reaction was "here we go again" – here is yet another black eye for the PPACA rollout.

HealthPocket.com, which is based in Sunnyvale, CA, found that eight of the top 10 medical services excluded from health insurance policies before the PPACA are also excluded from insurance policies on the new public exchanges. "There hasn't been a dramatic change from the pre-exchange market to the post-exchange market," Kev Coleman, HealthPocket.com's head of research and data, told me last week.

But on close examination, Coleman says, it becomes apparent why the pre-exchange and post-exchange Top 10 lists are nearly identical, for a host of financial, historical and moral reasons. "The health system expresses itself in that Top 10 list," he says.

The No. 1 medical service excluded from insurance policies before and after creation of the new exchanges is long-term care, which is associated with burdensome costs. "Long-term care is extremely expensive," Coleman said. "If you're inside any institutional facility, it costs tens of thousands of dollars."

Two of the other classes of medical services that appear on both lists, dental and vision care, have historically tenuous holds in the health insurance marketplace. "Originally, people paid out of pocket for all their healthcare needs," Coleman said. "Things like dental insurance and vision insurance come along much later."

And, he says, a strong moral case can be made against health insurance policies covering cosmetic surgery, which holds the No. 2 slot on both Top 10 lists of excluded medical services.

Evidence-based Medicine Raises Questions of Cost
Coleman and a pair of medical ethicists I spoke with Monday said the HealthPocket.com study contains elements of a brewing conflict over evidence-based medicine.

"Health insurance costs reflect costs of care," Coleman said, adding that evidence-based medicine seeks to "bend the cost curve by covering procedures that have the best clinical outcomes. But then you get into a very sensitive area."

Harald Schmidt, MA, PhD, an assistant professor at the University of Pennsylvania's Department of Medical Ethics and Health Policy, told me that doctors will have difficulties following the dictates of evidence-based medicine when treating individual patients. "They are very often at the sharp end of patients asking for something they saw on TV," he said of physicians. "On other things, there may be stronger shades of gray."

The murky areas present quandaries for all healthcare providers, Schmidt said. "Should you pay for useless care? That's the easy case. But what do you do when something works but it is expensive?" he said. "That's the really thorny one… There are always value judgments involved. That's something we're going to be looking at in the future as we define value when we have to figure cost into the equation."

One set of solutions to pay for treatments that are expensive but effective has been the steady increase in copays and other forms of cost sharing, Schmidt said: "Coverage alone isn't the only thing that matters."

Arthur Caplan, PhD, director of the Division of Medical Ethics at NYU Langone Medical Center, emphasizes that knowing the probability of clinical outcomes does not obviate the need to make value judgments about medical services that are marginal, longshots, or offer low benefits at high cost. "If you don't get agreement on the ethics, the evidence isn't enough," he said.

The Limits of Revolution
For those of you who find the HealthPocket.com study yet another discouraging report from the frontlines of the nation's healthcare reform battles, take comfort in humanity's past experience with revolution before you give up on the PPACA's impact in the future.

One of my first political science courses as an undergraduate included theoretical analysis of the French Revolution. I can see the instructor in my mind's eye and recall one of his fondest maxims: Revolution cleanses a society of its worst abuses, but fails to wash away the majority of longstanding institutions and traditions.

The evolution of the PPACA appears to be following this maxim.

President Obama's hallmark domestic policy initiative has been blunting the worst shortcomings of the US healthcare system, for example, by requiring insurance policies to cover pre-existing conditions. But it is unrealistic to expect the PPACA alone to totally transform the practice and financing of medicine.

"[The Obama administration] is finding that there's still a combination of unintended consequences as well as large issues that are not addressed," Coleman said.

The PPACA's focus on access and affordability has left the question of essential benefits in health plans largely off the revolutionary menu. "We never really have had a fight about benefits," he said.