Basic principles of economics suggest that health insurers should seek to avoid covering sick individuals and attempt to minimize the amount they have to spend if, despite the insurer's best efforts, such individuals enroll in coverage. The drafters of the Affordable Care Act recognized this natural tendency of insurers and put in place multiple provisions aimed at avoiding such behavior. One such tool was the requirement that all health insurers in the individual and small group markets cover an identical, comprehensive set of benefits known as the Essential Health Benefits (“EHBs”). EHBs were designed to ensure that consumers are able to access comprehensive coverage, but also to prevent insurers from trying to avoid high-risk enrollees by designing plans that appeal only to the healthy. Congress did not, however, statutorily define the full package of benefits, instead delegating primary authority for that task to the Department of Health & Human Services (“HHS”). This article argues that HHS has implemented the EHB requirements in a manner that appears structurally incapable of achieving the goals of the statute. By utilizing a vague definition of benefits, allowing benefit substitutions, and failing to limit use of service-level selection tools, HHS has permitted insurers to compete for low-risk insureds, avoid paying for certain high-cost treatments, and prevented consumers from making fully informed purchasing decisions.

中文翻译：

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未能定义基本健康益处的监管失败

经济学的基本原理表明，健康保险公司应设法避免为生病的人提供保险，并尽量减少他们必须花费的金额，如果尽管保险公司尽了最大努力，这些人还是参加了保险。《平价医疗法案》的起草者认识到保险公司的这种自然趋势，并制定了多项旨在避免此类行为的规定。一个这样的工具是要求个人和小团体市场中的所有健康保险公司都涵盖一组相同的、全面的福利，称为基本健康福利 (“EHBs”)。EHB 旨在确保消费者能够获得全面的保险，同时也防止保险公司通过设计仅对健康人有吸引力的计划来避免高风险参与者。然而，国会并没有 法定定义一揽子福利，而不是将这项任务的主要权力委托给卫生与公众服务部（“HHS”）。本文认为，HHS 实施 EHB 要求的方式在结构上似乎无法实现法规的目标。通过使用模糊的福利定义、允许福利替代以及不限制服务水平选择工具的使用，HHS 允许保险公司竞争低风险被保险人，避免支付某些高成本治疗，并阻止消费者充分知情的采购决策。本文认为，HHS 实施 EHB 要求的方式在结构上似乎无法实现法规的目标。通过使用模糊的福利定义、允许福利替代以及不限制服务水平选择工具的使用，HHS 允许保险公司竞争低风险被保险人，避免支付某些高成本治疗，并阻止消费者充分知情的采购决策。本文认为，HHS 实施 EHB 要求的方式在结构上似乎无法实现法规的目标。通过使用模糊的福利定义、允许福利替代以及不限制服务水平选择工具的使用，HHS 允许保险公司竞争低风险被保险人，避免支付某些高成本治疗，并阻止消费者充分知情的采购决策。