Balm's Away

  • by: |
  • 07/16/2012

Is there no balm in Gilead?  Is there no physician there?
-- Jeremiah, viii. 22

Remember when the President said that, under his healthcare reform plan, “If you like your doctor, you can keep your doctor”? Well, that turned out to mean – “If your doctor accepts your new insurance plan, you can keep your doctor.” As my grandmother used to say, “A half truth is a whole lie.”

Now, we must grapple with an even more serious attack on the doctor/patient relationship – essential health benefits. Under the law, insurance policies sold to individuals and small businesses must cover 10 so-called “essential health benefits,” including hospitalization, maternity care and prescription drugs. (See the complete list of benefits here.) But each state will determine how insurance companies cover those benefits in that state.

Or will they?

Representatives Henry Waxman (D-Calif.), Sander Levin (D-Mich.) and George Miller (D-Calif.), ranking members, respectively, on the House Energy and Commerce, Ways and Means and Education and the Workforce Committees, sent a letter to HHS Secretary Kathleen Sebelius (PDF) about the essential health benefits bulletin. The lawmakers contend that when they wrote the Patient Protection and Affordable Care Act, the essential health benefits package was intended as a federal decision, and that one of the primary goals of the healthcare reform law was to create a consistent and comprehensive level of coverage for Americans nationwide.

So, according to these lawmakers, it’s Washington that’s going to decide what’s essential and what’s not – further disempowering a physician’s ability to practice medicine. It’s another step towards one-size-fits-all medicine – the polar opposite of personalized medicine.

This issue of essential health benefits – what they are and who calls the shots – is at the crux of the battle against government-run healthcare.

Late last week, according to BioCentury, a group of 28 Representatives sent a letter to HHS expressing concern about a CMS proposal that may allow insurers to cover only one drug per therapeutic class under the Affordable Care Act's essential health benefits (EHB) plans. The group said a requirement that insurers cover only one drug per therapeutic class would be "overly restrictive," adding that the policy ignores patients' clinical needs and would lead to poorer clinical outcomes and greater healthcare costs.

The group urged HHS to require the plans to cover "all or substantially all" drugs for six therapeutic classes: antidepressants, antipsychotics, anticonvulsants, antiretrovirals, antineoplastics and immunosuppressants. The group noted that products in these classes are not clinically interchangeable, and that the products often have a high discontinuation rate because of lack of efficacy or side effects, requiring patient access to and coverage for multiple products in the same therapeutic class. CMS implemented the same requirement for Medicare Part D in 2006.

While “what” is defined as “essential” is, of course, crucial – the issue of “who” is paramount.

Do you really want Henry Waxman telling your doctor how to practice medicine?


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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