Secretary must consider most vulnerable when determining essential benefits package

{mosads}In order for the ACA to work, patients must have access to a wide range of health care products and treatments. The limitation of essential benefits proposed in the IOM report is particularly troubling to NAMI because coverage in the small group market has a tradition of either excluding categories of treatments and benefits for mental illness or imposing arbitrary limits or conditions that apply only to mental health benefits. This is unacceptable and runs contrary to the very design of the exchanges: to aggregate risks, create economies of scale, and spread costs across the larger markets and avoid the inefficiencies, adverse risk selection and high costs of the small group market.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires group health plans to cover mental health and addiction treatment on the same terms as medical-surgical benefits. There is an exception from the law for employers with 50 or fewer workers, which is why NAMI is so concerned about the IOM recommendation that small employer plans be used as a model, which would tie essential health benefits to a market largely out of compliance with mental health parity. Adopting a model that discriminates against people living with mental illness would not only be devastating to those patients but would also raise health costs for the entire population. NAMI urges the essential health benefits be based on a large market model that is more fully compliant with the Wellstone-Domenici law, where coverage for mental illness is more durable and comprehensive.

Finally, NAMI would like HHS to adopt standards to ensure that patients have access to medically appropriate care and decline to set national standards for whether individual items and services are either included or excluded. When updating the essential health benefits package, the Secretary should instead allow for some flexibility to ensure that new therapies and treatments are covered once they become available. This is not only important to people living with mental illness but all patients with chronic illness or disease and the wider population as a whole. When patients have access to the latest innovations and newest treatments, they will naturally have healthier outcomes, which would also help with costs over the whole system.

By designing an essential health benefits package that works for the entire population, HHS can go a long way towards ensuring the success of health care reform. Plans that offer a wide range of products and treatments, follow the laws regarding mental health parity, and ensure access to medically appropriate care without setting national standards for individual items and services will lead to a healthier nation and a more affordable health care system. After all, that is the goal President Obama laid out when the debate over health care reform began.

Sperling is Director of Legislative Advocacy at the National Alliance on Mental Illness