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What's Essential?

By Dr. Raag Airan

During my last year in medical school, I finally went and took advantage of my one free vision exam a year that I had guaranteed through my student health plan. Admittedly, I was pretty bad then (and still am...) about using the primary care I was entitled to, even as I was learning to work as a health care provider.

My appointment went well enough. The optometrist said I had great overall vision, although I had a slight astigmatism in each eye that minimally affected my left eye moreso than my right. I asked him if I needed to correct my vision with glasses or lenses. He initially relented, saying my defect was so slight I had barely noticed anything through all those years in school. But, as I was going into radiology, I pushed for a prescription for my first set of glasses ever. Since I put on that pair, life has been totally different. It’s as if I upgraded from regular vision to HD. I now wear my glasses whenever I’m awake even though I don’t need to - why should I go about with worse vision?

While my upgrade has been great, I wonder if it was necessary. In particular, I got pretty steep discounts on my vision care from the initial appointment to my purchase of frames and lenses. I had made it through graduate school, medical school, and the match without any vision correction. While as a radiologist it would certainly behoove my future employer to make sure I had the best vision possible, I don’t see why the larger population should fund my discounted vision care through government subsidies and the like.

As we move to mandatory insurance for all and specific requirements insurers have to meet for a basic insurance plan, the critical question is this: what makes up the essential benefits package the state deems is necessary for everyone to have? Are corrective eyewear for a non-incapacitating vision defect essential? What about spinal fusion for back pain? Or third-line, or even second-line chemotherapy?

The Obama administration has given some guidelines on what it thinks an essential package is, but has left the final word to the states. The up-side of this is we could have 50 ongoing experiments into what essential benefits packages work best for outcomes and cost - and eventually implement what works best on a larger scale. The down-side, of course, is that cash-strapped states will have a race to the bottom in terms of what they consider to be essential. The language of the ACA and the federal guidelines leave a lot of interpretation to the user.

So my question is: what health care services are truly essential for everyone to have guaranteed access to?

There are many things that are nice, like my discounts on corrective lenses, that don’t necessarily lead to a healthier life. The tough choices will lie in deciding what is nice and what is essential, and cutting out the former from public funding and infrastructure.

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