Health Care Reform: Defining What Minimum Benefits Should Be

As a health care professional, you’re probably well aware of the plight of the under-insured – those consumers who are faced with a medical crisis, only to find out the hard way that their insurance coverage is woefully inadequate. These folks can find themselves faced with high bills – even a potential bankruptcy – because of a high deductible, benefits that exclude certain diagnostic tests or treatments, policies that only cover hospitalizations, or annual caps on payments. And to some extent, geography is destiny when it comes to health insurance, because what must be covered by law in one state is not necessarily mandated in another state.

This is where the concept of “minimum benefits” comes into play. The term refers to a baseline set of benefits that would be mandated by law, to make sure everyone has a certain level of coverage when they buy a health policy. It would not only reduce the number of people faced with catastrophic costs, but would make it easier for consumers to compare cost and quality of coverage when shopping for insurance. Consumers could then purchase additional coverage according to their needs and budget.

The Patient Protection and Affordable Care Act (PPACA) calls for just such a baseline. The law lists ten categories of services that must be covered, including areas that have been restricted in the past, like maternity care, prescription drugs, mental health, pediatric care, etc. And it states that the Department of Health and Human Services (HHS) shall define which medical services within these categories will be mandated as essential to every insurance policy.

Creating a set of benefits like this is no easy task. Patient advocates and many health care providers are in favor of increasing coverage, with an emphasis on primary care and preventive services. Insurers and employers want to decrease coverage, to shift more of the costs to the consumer. The Institute of Medicine, which was asked to formulate recommendations for a set of minimum benefits, noted that the medical effectiveness of various services should be considered when defining what policies should cover. It recommended that the minimum benefits be patterned after existing small group plans – rather than the more comprehensive and more expensive large group plans offered by some employers.

While the health care and insurance industries were waiting for a national standard of minimum benefits to be announced, HHS instead decided it would leave it up to the individual states to define minimum benefits – at least until 2016, when it would re-evaluate this approach and re-visit the issue of a national standard.

Critics of this strategy say that many people could end up with less robust coverage than the reform originally intended. Less likely is the opposite problem – that some states will make the benefits package so widely comprehensive that insurance becomes prohibitively expensive.

So what does this all mean for nurses? At this point, it’s hard to say – because now it seems likely that insurance benefits will continue to vary widely from state to state. But it’s probably safe to say mandated minimum benefits will expand the need for primary care providers, which will in turn expand employment opportunities for nurses within private practices. It’s also likely that an expanded emphasis on coordinating care across all providers will create a need for more highly skilled nurse case managers.

No matter what happens with the minimum benefits issue, other initiatives like accountable care organizations and readmission reduction programs are likely here to stay, making a strong case that greater accountability for patient outcomes rests on health care workers at all levels. Do you have what it takes to meet these new challenges? What can you do to prepare for the job skills and expectations you will soon meet in the face of reform? If you’re already considering going back to school, American Sentinel has some tips for you, to help you plan your education with health care reform in mind. There are other ways education can further your career as well – for example, through programs that prepare nurses for a specialty in case management and infection control.

Develop your critical thinking skills and empower yourself with knowledge, through a RN to BSN or RN to MSN degree. American Sentinel University is an innovative, accredited provider of online nursing degrees.