Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115, USA.
Psychiatr Serv. 2010 Nov;61(11):1074-80. doi: 10.1176/ps.2010.61.11.1074.
Under the newly enacted health reform law, millions of lower- and middle-income Americans will purchase individual or family health insurance through state-based markets for private health insurance called insurance "exchanges," which consolidate and regulate the market for individual and small-group health insurance. The authors consider options for structuring choice and pricing of health insurance in an exchange from the perspective of efficiently and fairly serving persons with mental illness. Exchanges are intended to foster choice and competition. However, certain features-open enrollment, individual choice, and imperfect risk adjusters-create incentives for "adverse selection," especially in providing coverage for persons with mental illness, who have higher overall health care costs. The authors review the experience of persons with mental illness in insurance markets similar to the exchanges, such as the Massachusetts Connector and the Federal Employees Health Benefit Program, and note that competition among health plans for enrollees who are "good risks" can undermine coverage and efficiency. They review the possible approaches for contending with selection-related incentives, such as carving out all or part of mental health benefits, providing reinsurance for some mental health care costs, or their preferred option, running the exchange in the same way that an employer runs its employee benefits and addressing selection and cost control issues by choice of contractor. The authors also consider approaches an exchange could use to promote effective consumer choice, such as passive and active roles for the exchange authority. Regulation will be necessary to establish a foundation for success of the exchanges.
根据新颁布的医疗改革法案，数以百万计的中低收入美国人将通过州级市场购买个人或家庭医疗保险，这些市场被称为“保险交易所”，它们整合并规范了个人和小团体医疗保险市场。作者从为精神疾病患者提供高效和公平服务的角度出发，考虑了在交易所中构建医疗保险选择和定价结构的各种方案。交易所旨在促进选择和竞争。然而，某些特征——开放式注册、个人选择和不完善的风险调整器——为“逆向选择”创造了激励，尤其是在为精神疾病患者提供保险方面，因为他们的整体医疗费用更高。作者回顾了类似交易所的保险市场中精神疾病患者的经验，例如马萨诸塞州连接器和联邦雇员健康福利计划，并指出，对于“优质风险”的参保人来说，健康计划之间的竞争可能会破坏保险覆盖范围和效率。他们回顾了应对与选择相关的激励措施的可能方法，例如将全部或部分心理健康福利剔除、为部分心理健康护理费用提供再保险，或者他们更倾向的选择，以雇主管理员工福利的方式运营交易所，并通过选择承包商来解决选择和成本控制问题。作者还考虑了交易所可以用来促进有效消费者选择的方法，例如交易所管理机构的被动和主动角色。监管对于交易所的成功是必要的。
