Value-Based Mandated Health Benefits
Amy B. Monahan
Mandated health benefit laws figure prominently in health reform debates. These laws, which are primarily enacted by the states, require health insurers to cover specific medical treatment, services, or supplies such as mental health treatment, mammograms, or diabetes testing supplies. Critics argue that mandated health benefit laws increase health insurance costs, decrease consumer choice, and often are the product of rent-seeking, rather than sound public policy. This Article seeks to further the discussion of mandated health benefit laws by systemically identifying permissible rationales for such laws. The justifications identified include addressing (1) market failure that leads to non-availability of coverage, (2) suboptimal utilization of a medical treatment or service, (3) undesired insurance company coverage determinations, (4) cognitive shortcuts and biases, and (5) failures in the group market. For any of these justifications to be used, however, there must also be a viable justice claim for such coverage or the coverage must have a positive cost-benefit or cost-efficiency analysis compared to non-coverage. This Article argues that being precise about the justification for a mandated health benefit law allows such a law to be precisely tailored to solving the problem which justifies its existence. These tailored mandates, referred to as value-based mandates, continue to advance the important policy goals of mandates, while being significantly more efficient than non-value-based mandates. The Article concludes with three case studies of existing mandated benefit laws, analyzing each under the value-based framework set forth in the first part of the Article.