Benefits Board Is Prime Player in Health Debate

They would decide what treatments would be covered. They would set the amount that patients pay for a doctor’s visit or a specific medical procedure. If federal funds should run short, they would impose limits on mental health coverage.

They would be appointed by the President, subject to Senate confirmation. But once in office, the public would have scant opportunity to influence their decisions.

Despite their broad powers, nobody knows who would serve on the National Health Benefits Board, which would be created by the health reform legislation that is to be debated on the Senate floor beginning today.

Opponents are certain to attack the board as the epitome of big government: faceless bureaucrats who would make potentially life-or-death decisions without direct public accountability.

“To have a board actually define in detail what the benefits structure will look like is the most extreme example of a hyperpoliticized process,” said Richard I. Smith, a health policy analyst at the Assn. of Private Pension and Welfare Plans. Others said that concentrating coverage decisions in a federal bureaucracy would be likely to delay innovative treatments.

For instance, Deborah Steelman, a health care lobbyist and GOP strategist, noted that the federal government did not decide to cover heart transplants under Medicare until “three to five years after they became fairly routine in the private market.”

But many analysts said that the board’s authority and lack of accountability actually would be its chief strengths. “A board can take more time in making those decisions than Congress. And it can make them in a less political atmosphere,” said David Eddy, a physician in Jackson Hole, Wyo., who has been advising members of Congress of both parties.

“Any time you create a new government entity, you are obviously vulnerable to charges of big government,” said analyst Drew Altman, president of the Kaiser Family Foundation, a nonprofit group that studies health issues. “So I think it’s wise for proponents of this approach to present it as a consumer protection issue.”

If every American is to be provided with health insurance--President Clinton’s bottom line--there will have to be a universally available standard benefits package. And one of the key questions is who would define that very visible payoff.

“It’s been a sleeper issue all along. If it had been proposed all by itself, it would have been highly controversial,” Steelman said.

The board proposal has a long way to go before it becomes reality. It is not in the House plan, so even if it passes the Senate, it would have to be approved by the House. It is, however, one of several second-tier issues that has the potential to ignite into a full-fledged fight, along with the larger issues of universal coverage and employer mandates.

Unlike the President’s proposal, which defined the scope of coverage in excruciating detail, Mitchell’s bill only specifies 16 general categories of medical services to be covered, leaving to the board specific decisions about the scope and duration of coverage.

To some extent, that may open Mitchell’s approach to the type of attack that the White House launched against a plan by Rep. Jim Cooper (D-Tenn.), which also proposed a board to define a standard benefits package. The President and other Administration officials repeatedly criticized Cooper’s approach by saying that the public deserves to know at the beginning precisely what it will be getting.

But on Monday, a senior Administration analyst defended Mitchell, saying that the creation of a board is “a way of getting around having to define everything--right down to how many days of coverage and what the deductibles should be.”

Ironically, the Clinton plan that was proposed last September featured an even more powerful board--one that would have been allowed to set national standards and oversee the establishment and administration of health systems throughout the country. It was quietly dropped after a firestorm of criticism over the bureaucratic nature of Clinton’s plan.

Under Mitchell’s plan, the board’s authority would be markedly curtailed. Still, the body would wield considerable clout.

It would define what treatments and procedures--and how frequently they should be used--are medically necessary and appropriate and therefore eligible for coverage.

In addition, although not initially expected to be covered, Mitchell’s bill requires the board to specifically study the cost of providing in-vitro fertilization as well as preventive and restorative dental care for adults.

Also, if mental health coverage becomes too costly, Mitchell would allow the board to place limits on such coverage, starting with hospitalizations and then outpatient psychotherapy for adults. Both major Democratic bills envision mental health coverage, but many skeptics have said that the cost could be prohibitive.

The leading health reform bill in the House, put together by Majority Leader Richard A. Gephardt (D-Mo.), does not propose a national health board because it simply requires that all Americans receive the coverage now provided by Medicare, the government-financed insurance program for those over 65.

In addition, however, Gephardt’s bill specifies various “enhancements” and out-of-pocket spending limits, such as annual deductibles of $500 for an individual and $750 per family and outpatient prescription drug coverage with a separate deductible of $500, 20% cost-sharing and a $1,000 annual out-of-pocket limit.

Under Mitchell’s proposal, the board would develop three specific schedules for cost-sharing--that is, the out-of-pocket payments by consumers. According to Mitchell’s plan, the three options are a “low cost” fee schedule similar to that of a typical health maintenance organization, a “high cost” fee schedule resembling a traditional fee-for-service plan and a hybrid of the two that would allow subscribers to pay a higher fee if, on occasion, they wish to see a doctor outside their plan.

The board would have an annual budget of at least $5 million. No more than four of its members would be from the same political party. Members would serve staggered, six-year terms.

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