Haeder Simon F
Department of Political Science, University of Wisconsin-Madison, 110 North Hall, 1050 Bascom Mall, Madison, WI 53706, United States.
Health Policy. 2014 Dec;118(3):285-91. doi: 10.1016/j.healthpol.2014.09.014. Epub 2014 Oct 5.
The Essential Health Benefits provisions under the Affordable Care Act require that eligible plans provide coverage for certain broadly defined service categories, limit consumer cost-sharing, and meet certain actuarial value requirements. Although the Department of Health and Human Services (HHS) was tasked with the regulatory development of these EHB under the ACA, the department quickly devolved this task to the states. Not surprisingly, states fully exploited the leeway provided by HHS, and state decision processes and outcomes differed widely. However, none of the states took advantage of the opportunity to restructure fundamentally their health insurance markets, and only a very limited number of states actually included sophisticated policy expertise in their decisionmaking processes. As a result, and despite a major expansion of coverage, the status quo ex ante in state insurance markets was largely perpetuated. Decisionmaking for the 2016 revisions should be transparent, included a wide variety of stakeholders and policy experts, and focus on balancing adequacy and affordability. However, the 2016 revisions provide an opportunity to address these previous shortcomings.
《平价医疗法案》中的基本健康福利条款要求符合条件的保险计划为某些宽泛定义的服务类别提供保险范围，限制消费者的费用分摊，并满足某些精算价值要求。尽管根据《平价医疗法案》，美国卫生与公众服务部（HHS）负责这些基本健康福利的监管制定工作，但该部门很快将这项任务下放给了各州。不出所料，各州充分利用了卫生与公众服务部给予的回旋余地，各州的决策过程和结果差异很大。然而，没有一个州利用这个机会从根本上重组其医疗保险市场，只有极少数州在其决策过程中实际纳入了复杂的政策专业知识。结果，尽管保险覆盖范围大幅扩大，但州保险市场的事前现状在很大程度上得以延续。2016年修订案的决策应该透明，要有广泛的利益相关者和政策专家参与，并且要注重平衡保险的充分性和可承受性。然而，2016年的修订案提供了一个解决这些先前不足的机会。
