CAUSE: Beyond 15 years

All U.S. residents are enrolled in CAUSE Part I and Part II. All U.S. residents continue to have the option to purchase private supplemental plans.

After 15 years the CAUSE approach will be completely implemented. Specific benefits and deductibles associated with covered services will be determined by the national health board.

As in the previous years of CAUSE, private wraparound plans may be purchased to cover deductibles and out-of-pocket costs for services covered by CAUSE and individuals wanting more than the covered services in the basic plan will be able to buy supplemental coverage through private insurance companies. CAUSE private supplemental plans would still not be able to deny coverage to individuals due to health status. Individuals who want more covered services than those available in the basic plan will be able to purchase a secondary policy from private insurers. This would not be governmentally financed or subsidized. Individuals or firms offering supplemental coverage will not receive tax deductions.

The CAUSE approach will financially cover services determined by the national health board to be successful, after receiving input from state and sub-state regional health boards. These would be services that are found to be optimal for the nation’s health, based on the principles of evidence-based medicine. Covered services for the basic plan will be determined by the national health board, following recommendations by the NIH, research analysts, and all of the public input of the regional boards.

These services would include inpatient care, prescription drugs, primary prevention, outpatient care, mental health, vision, hearing services, dental care, emergency care, long-term care separating the medical component from the medical services only to encourage in-home care, physical therapy, occupational therapy, and hospice care. Only the healthcare components of long-term care (and not the so-called “hotel” component) will be covered by CAUSE.

Individuals will be able to rely on private long-term care insurance or Medicaid for these components of long-term care. Not everything in the above services will necessarily be included in the basic plan. It is important that the covered services need to be recognized as medically necessary so as to not undercut basic health care access. In year 15, there will not be cost-sharing for items in which evidence-based medicine has shown cost-saving and benefit to both patient and society so that there is no barrier to obtain the service. There will be cost-sharing for other items not shown to be cost-saving but that are necessary to avoid overutilization of the system.

Medicaid eligibility will be established by states, but minimum eligibility will be at 150 percent of the FPL. Medicaid will pay premiums, deductibles, long-term care hotel component, and additional chronic care benefits as in many current state plans. States will not be able to establish reimbursement rates that are lower than the CAUSE approach. The CAUSE approach will continue to contract with private intermediaries to help process claims and help with diverse managed care and special population plans.