Perspective
Fair Enough? Inviting Inequities in State Health Benefits
N Engl J Med 2012; 366:681-683February 23, 2012
Comments
open through February 29, 2012
- Article
The Obama administration scored a political point in December with its bulletin on essential health benefits, appeasing critics of the Affordable Care Act (ACA) by giving states the right to determine what those benefits should be.1 The proposal is politically savvy. But is it fair?
The ACA stipulation that certain essential health benefits must be offered by health plans participating in the new state insurance exchanges is a huge step toward a more fair and equitable health care system. The 30 million uninsured Americans who have had limited or no access to care will be guaranteed at least some health care; for some, this could mean seeing a doctor for the first time in years.
Now, the policy outlined by the secretary of health and human services (HHS) gives states considerable flexibility in selecting benchmark plans to which all other health plans in that state must be “substantially equal.” Health plans will be allowed to change the makeup of specific benefits and set their own quantitative limits. So, for example, the number of psychologist visits permitted to a patient with depression or the number of hospital days provided after surgery can vary according to state. Some states may be more generous than others, and where one lives will be a key determinant of the benefits one receives. Moreover, the Department of Health and Human Services is “considering whether to allow substitution across the benefit categories,” which would mean that some “important services or benefits in particular categories” could be eliminated altogether. Thus, there will be no uniform standard for the quantity or quality of health care that must be provided.
But what if this policy means shoddy health care for some patients and top-of-the-line health care for others — a two-tiered system? And what if variations in quality lead to disability, dysfunction, complications, or premature death? Quite different outcomes can be achieved in a person with full access to high-quality health care and one who lacks such access, even if the two have the same health condition. Hypertension, for instance, affects almost 20% of the U.S. population, yet millions of Americans have undiagnosed hypertension, and only 58% of patients receive appropriate treatment.2 And research shows that less than 3% of postmenopausal women with distal radial fractures received bone-density testing, and less than 25% received osteoporosis treatment within 6 months after their fracture occurred.3 Such gaps in care increase the risk of poor health outcomes.
Moreover, a state-by-state approach carries potential for discrimination against patients with rare, severe, or costly health conditions. Refsum's disease, for instance, which is caused by a lack of the enzyme that breaks down phytanic acid, leads to skin disorders, loss of the sense of smell, night blindness, deafness, and heartbeat abnormalities that may result in sudden death. Neurologic, ophthalmologic, dermatologic, and generalist care are necessary for its diagnosis and evaluation. Treatment involves lifetime adherence to a strict special diet and close monitoring by clinicians; plasmapheresis and cochlear implants may be needed. Functioning and even survival could be compromised by a lack of access to high-quality care. Yet patients' ability to obtain such care when they need it will probably vary according to state. Currently, a Medicaid patient in Mississippi, for example, is permitted only 12 physician visits per year, whereas a Medicaid patient in New York has “beneficiary-specific utilization thresholds” that are based on age, sex, clinical diagnosis, prescription drugs, and procedures.4 Although a uniform national benefits package might also omit rare or costly health conditions, it would at least avoid the troubling arbitrariness of state-based variation in coverage. And if it proved wanting, correcting one national package to ensure comprehensive coverage of high-quality services would be more efficient than attempting to revise dozens of different state plans.
I believe that the HHS proposal reflects an inadequate view of equality. A better approach would be to establish uniform standards so that all Americans would have access to the same high-quality goods and services.5 Such a policy could mean the difference between life and death, and it has been well tested and long debated. Indeed, this solution is grounded in the Aristotelian principles of vertical and horizontal equity. Vertical equity calls for different quantities and intensities of goods and services for persons with different needs. For example, patients with conjunctivitis and those with glaucoma need different treatments to restore normal ocular function. Horizontal equity demands that persons with the same needs receive the same treatment. Providing such persons disparate care — as might well happen under the flexible system established by HHS — represents horizontal inequity.
Those who object to the uniform-standards solution will counter that it idealistically and naively seeks, as measures of fairness, the same health outcomes and the same amounts of care for everyone. In fact, however, it is based on the principle of proportionality — the notion that similar cases should be treated similarly and different cases differently, in proportion to their differences. Medical cases in which the health needs are the same are deemed alike; those in which the health needs are different are considered unalike. Such a solution would also require that health care be provided in keeping with medical necessity and medical appropriateness and that patients and their doctors — not state insurance exchanges, state governments, or private health plans — be the ones to make such assessments, within the scope of national standards.
Persons with the same health condition may require different amounts of care because of differences in severity or in their ability to improve their health with the available resources. Two patients may both have diverticular disease, for example, but one may simply have diverticulosis, which may be treatable with a dietary change or mild pain medication, while the other has diverticulitis, which might require surgery and colon resection. The principle of equal access I propose would call for differential provision of health care resources to achieve the same desired outcome for both patients — giving each what he or she needs to reach a medically determined level of functional health.
There is no perfect health care system. But setting a goal of equal access to high-quality, evidence-based care would be a step in the right direction. Unceasing effort to standardize comprehensive health coverage and reach a gold standard of care is essential to attaining this goal.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1200751) was published on February 8, 2012, at NEJM.org.
Source Information
From the Yale School of Public Health, the Yale School of Medicine, the Yale University Graduate School of Arts and Sciences, and Yale Law School — all in New Haven, CT.
- References
References
1
Essential health benefits bulletin. Baltimore: Center for Consumer Information and Insurance Oversight, December 16, 2011 (http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf).
2
Closing the quality gap: hypertension care strategies: fact sheet. Rockville, MD: Agency for Healthcare Research and Quality, April 2004. (AHRQ Publication No. 04-P018.)
3
Freedman KB ,Kaplan FS ,Bilker WB ,Strom BL ,Lowe RA . Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am 2000;82:1063-1070
Web of Science | Medline4
Kaiser Family Foundation. Medicaid benefits: online database (http://medicaidbenefits.kff.org/index.jsp).
5
Ruger JP. Health and social justice. Oxford, UK: Oxford University Press, 2009.
- Comments (8)
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8 Reader's Comments
Mark Davies | Physician | Disclosure: NoneUnited KingdomFebruary 10, 2012Equality of care or quality of care?
An imposed compromise from the beginning, however good, can easily become mediocrity for all. Different interpretations of the start point allow a natural experiment which can be used to improve better quality for all.
MICHAEL WILLIAMS, MD | Physician | Disclosure: NoneLAKEWAY TXFebruary 10, 2012The New England Journal of Fairness Determination
Serious readers of the Journal have observed a change over the years in the relative weighting of "science" versus "politics" content. It was quite rare for a Journal issue to incorporate a health policy related article prior to 1999. Since then, the percentage of articles with non-clinical/non-research content has gradually increased each year. Now, it is not uncommon for a full one quarter of the articles in an individual issue of the Journal to be health policy related.
And now this....Is this legislation or that legislation "fair?" The Journal, in my view, should not be a kindergarten playground, full of youthful antagonists pouting about what is fair or not fair.
There are many other journals that are exclusively devoted to health policy where these topics should be debated. Clearly, the nation needs all the physician input that can be obtained on one of the most important issues of our age. No clear-headed observer can doubt this. But for every article on health policy accepted by the Journal, an article on clinical medicine, medical education or basic science research is cut.
Sadly, excessive dilution of core content may be the Journal's demise.Joseph Cronin | Resident | Disclosure: NoneFebruary 09, 2012A "two-tiered system"?"
The author seems to somehow be surprised that PPACA might lead to a two-tiered medical care system. This, of course, is the exact intent of the legislation. What do physicians read in their time away from the office??? Come 2014, we will have a two-tiered system...very similar to Australia and other developed countries.
DAVID MUSHATT, MD | Physician | Disclosure: NoneNEW ORLEANS LAFebruary 08, 2012The Voice of Reason
Dr. Ruger's comments are right on!
In a country such as ours that values the sanctity of the individual, equal rights for all and compassion, it is folly to allow all 50 states to invent their own ACA standards for health insurance coverage. Access to good healthcare is not a luxury but a basic human right in the US, and should not be subject to the whims and arbitrariness of state governments.Michael Bertaut | Other | Disclosure: NoneFebruary 08, 2012A bit hollow
Politically, PPACA put the Obama administration, and therefore his acolytes at HHS/CMS/CCIIO into an impossible position. If they followed the tilt of this article and stipulated a national standard, which states would they chose to slight?
The modeling I've seen suggests If they chose a relatively rich benefit package, a' la mandates from a state like New York, Vermont, or Massachusetts, it would have been impossible to create a 60-70% actuarial value plan within the limitations the Act imposes on things like deductibles, cost-sharing, and max out of pocket. Adding similar coverages to most of "flyover (low mandate) country" would have driven prices up so that established projections of federal subsidies in the Exchange would have been insufficient, and the uninsured would have stayed higher than expected.
Take a lower mandate package, impose it nationally, and you've put politicians in the mandate rich states (Blue states all, by the way) in position to either PAY for their extra coverage with state funds, or disappoint their base.
Catch-22, PPACA-style.FRED PEVOW, MD | Physician | Disclosure: NoneSANTA FE NMFebruary 08, 2012determining coverage
The most important thing is for medical doctors that treat the patients to make ALL these medical decisions whether at a state or federal level. Having academicians, bureaucrats, lawyers and politicians involved as in the past will be a catastrophe. It's way past time for us to get involved.
JONATHON ROSS, MD | Physician - Health Law/Ethics/Public Policy | Disclosure: NoneOTTAWA HILLS OHFebruary 08, 2012Unaffordable underinsurance
The "bronze" plans that will populate the state exchanges will have an actuarial value that will leave many acutely or chronically ill lower income participants of the exchanges with bankrupting health care bills since they will be paying 30% or more of the total. Who cares if the benefits are comprehensive if any serious illness will bankrupt you, covered or not. The new standard in the exchanges will be unaffordable under-insurance. All this fuss and bother to preserve the private insurance companies who drive us and our patients crazy playing mother-may-I to get permission for needed care.
We need an improved and expanded Medicare for all. It will save $400 billion or more yearly on administrative costs and cover everyone with comprehensive benefits with no co-pays and it will cost less than we are about to spend to prop up a sickness care non-system based on private insurance that will still leave 20 million uninsured. This is immoral and outrageous.
Uniform, but high quality professional satandards.
Unfortunately we already have unequal standards: Medicaid and the uninsured may receive unequal treatments based on their socioeconomic status. I feel it is a mistale to allow each state set its own standards. As professionals we doctors should do the best we can for each patient. That does not always mean the most, but it might.