Affordable Care Will Be the Goal for Most

Over the past few weeks we have begun to see coverage mandates that will make up the benefit designs on Health Exchanges in 2014.  This week, HHS adopted the IOM non-evidence based recommendations to include all forms of contraception as a preventive benefit, "free" of any out-of-pocket copays or deductibles.  Whether or not we even believe appropriate as a "preventive benefit", generic birth control pills are rather inexpensive, the branded products are not.  Yet, after August 1, 2012, all will be covered at no individual cost.  This is a wonderful opportunity for Pharma to accelerate their advertising of branded pills and raise the cost of this benefit for all responsible for paying premiums. For taxpayers who will subsidize the purchase of health insurance for some, and for the rest of us who purchase our plans without subsidy, the price of our insurance premiums just went up for all.

Universal coverage for disease prevention where no out-of-pocket costs are expected makes sense where there is good evidence the intervention will help the individual and the larger public.  Childhood immunization is the classic example as the intervention clearly effective at disease prevention as well as the spread of disease in the population.  It is much less clear whether cholesterol screening, diabetes screening, etc. should be "free" of individual responsibilty to pay a portion at the time of service.  But it is truely a stretch to say that society should foot the bill for all forms of pregnancy prevention, a condition that is hardly even considered a disease.  Using the underlying arguments in favor of such coverage, we could argue virtually everything we contemplate in health care prevents something.  Don't we contemplate an appendectomy to prevent a ruptured appendix and possible death?

For health care to remain affordable for all, benefits must primarily target the financial assistance necessary for an individual and family to weather a catastrophic event.  Secondarily, it is appropriate for benefits to support the use of preventive services that benefit both the individual and society at large.  Some of these preventive benefits may deserve consideration of no out-of-pocket costs but most should arguably require some responsibility from the individual. 

When President Obama argued for administrative simplification of health care, this was a code word for social reform and the same benefits for all, at a cost supported by society. It is important for all of us to think carefully about the benefit mandates that we will hear more and more about over the ensuing weeks.  Nothing is free and the question is when and how should individuals take responsibility for their own health costs?  In general, universal mandates increase the cost for us all, ultimately making health care unaffordable.