The Ever Shrinking Health Reform: After Demise of Long-Term Care, Take Action Against Limiting Essential Benefits

As the Affordable Care Act’s “individual mandate” to buy private health insurance is making its way to the Supreme Court (ironically, had the Act required everyone to take part in a social insurance system, it would have never raised a legal eyebrow), its remaining provisions are getting stripped down with alarming speed.

Last week the White House dropped the ACA’s long-term care program, because the Department of Health and Human Services (HHS) could not prove that the program would generate enough revenue to pay for its benefits. According to the ACA, funding for the program was not conceived as a matter of investing in people’s health (or in the right to a dignified life for people in old age or with disabilities) – on the contrary, the law required the program (Community Living Assistance Services and Supports, or CLASS) to sustain itself on private premiums without any public funds and to prove financial stability for 75 years prior to launch. As Medicare does not cover long-term care, seniors and people with disabilities who need home care will now only have the means-tested, cash-strapped Medicaid program to fall back on.

Just a few days earlier, another ACA provision was put into question by a report from the Institute of Medicine (IOM). The IOM had been asked to develop guidance for HHS to define the essential health benefits package for plans in the state-based insurance exchanges (their report did not recommend a list of essential benefits but set guidelines for how to develop such a list).

Instead of prioritizing people’s health and health needs, the IOM promoted the primacy of cost concerns in the definition of essential health benefits. The ACA requires that insurance plans par¬ticipating in the exchanges cover an “essential” package of diagnostic, preventive, and therapeutic services. Yet the IOM chose not to reflect on which services might be essential to protect people’s health, but instead focused on which services might fit the budget of the health care “consumer.”

In a shocking espousal of market ideology that treats health care as a commodity, the IOM panel put forward the following analogy: “One way to think about the EHB package is to compare HHS’s task to going grocery shopping. One option is to go shopping, fill up your cart with the groceries you want, and then find out what it costs. The other option is to walk into store with a firm idea of what you can spend and to fill the cart carefully, with only enough food to fit within your budget. The committee recommends that HHS take the latter approach to developing the EHB package and to keep in mind what small employ¬ers and their employees can afford.”

This primacy of the cost frame mirrors the current approach to public budgeting across the country, whereby critical policy decisions are made on the basis of existing funds (which are adjustable) rather than people’s fundamental needs and rights (which are absolute), and whereby options to raise additional funds to meet needs and protect human rights, including the right to health, are ignored.

The IOM also suggested that insurance companies, despite their financial interest in denying access to care, should decide on what is “medically necessary” in an individual medical case.

Take Action:

Medical professionals under the umbrella of Physicians for a National Health Program (PNHP) have prepared a sign-on letter in response to IOM’s focus on cost over health. Excerpts from the letter:

“We protest the Institute of Medicine’s (IOM) recommendation that cost rather than medical need be the basis for defining the “essential benefits” that insurance policies must cover when the federal health reform law takes effect in 2014. If adopted by the Department of Health and Human Services, this recommendation will sacrifice many lives and cause much suffering.  We call on Secretary Sebelius and President Obama to reject them.

[…]  Our patients urgently need what people in these other nations already enjoy: universal and comprehensive coverage in a nonprofit system that prioritizes human need over corporate profit.

The IOM committee was riddled with conflicts of interest, many members having amassed personal wealth and career success through their involvement with health insurers and other for-profit health care firms. Its recommendations were lauded by insurance industry leaders who have sought to undermine real health reform at every turn. As the Lancet noted on its Dec. 5, 2009, cover: “Corporate influence renders the U.S. government incapable of making policy on the basis of evidence and the public interest.” Sadly, the committee’s damaging recommendations suggest that this corporate bug has also infected the IOM.”