What’s an “affordable” health plan?

As a health futurist, I feel comfortable predicting that one of the hottest political issues for the next few years will be designing the “affordable” health plan that uninsured Americans must purchase in 2014.  The insurance overhaul laws delegate the general task to the Secretary of HHS, but they also dictate specific services that must be included in the mandated packages.  The process of combining regulatory authority with statutory mandates will be one big can of worms.  (The equivalent French expression, translated as a nest of poisonous snakes, provides an even better metaphor.) 

The reform laws themselves set the stage for a bitter battle by decreeing that plans must include many “basic” services to comply with the law—but defining them is one of more than a thousand “the Secretary shall…” delegations of authority in the legislation.  Having observed the promulgation of federal regulations for nearly 40 years, I do not foresee this process going smoothly.  It sets up intense battles between some of the most powerful constituencies in Washington.  Providers, payers, purchasers, pharma, and other suppliers and will fight to protect their interests under the negative-sum budget constraints built into the laws (if Congress continues to honor its current intent, another area of uncertainty). 

The new laws also identify preventive services that must be covered.  Many of these tests are politically popular, but they are also expensive and imprecise.  For example, the “affordable” health plans must pay all costs of breast and prostate cancer tests that are not clearly supported by scientific evidence or economic analysis.  Ironically, the debatable prevention mandates were legislated by the same Congress that made a major commitment to comparative-effectiveness research in the economic recovery law of 2009.  This policy conflict will further complicate the Secretary’s efforts to translate Congressional intent into viable, deficit-reducing regulations between now and 2014.     

In spite of these problems, a basic and affordable health plan must be developed.  It is an essential step for creating an efficient and effective health system.  However, I fear the politics of implementing insurance overhaul will get in the way of doing what needs to be done.  I am optimistic, on the other hand, that partnerships of dedicated stakeholders will develop good, progressive health plans in state and local markets.  I expect that I will be deeply involved in this quest.  Please join me by sharing your concepts of health plan design that reflect the medical science, technologies, and economic realities of the next decade.   In your view, what services should and should not be covered in a basic, affordable health plan?