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Essential Health Benefits Under Threat

The Affordable Care Act (ACA) created minimum federal standards, known as “Essential Health Benefits” (EHB), for the services that marketplace plans must cover. States must also provide EHB to beneficiaries eligible under the ACA’s Medicaid expansion. The current House bill would repeal the EHB requirement for Medicaid expansion beneficiaries, but in addition, negotiations are reportedly under way to eliminate EHB requirements in the individual and small-group markets. These changes could leave consumers without the coverage they need, at any price, as we’ve explained.

If the EHB requirements were eliminated, individual-market plans would quickly revert to pre-ACA benefit packages. Before the ACA, individual-market health plans often left out key services. For example, in 2011, 62 percent of enrollees had individual-market plans didn’t cover maternity care; 34 percent had plans that didn’t cover substance use treatment; 18 percent had plans that didn’t cover mental health; and 9 percent had plans that didn’t cover prescription drugs. That means that people with health insurance often discovered too late that their health plan wouldn’t pay for the health care they needed. And people who sought plans that covered services like maternity care or substance use treatment faced exorbitant premiums, since costs weren’t being spread across the full market.  

Although Republicans often refer to Essential Health Benefits as if they are a long list of mandated rules, they actually refer to ten basic categories of health benefits.  

Ambulatory Patient Services

Ambulatory services are outpatient services, such as doctor visits and same-day surgeries. Without coverage for outpatient services, people might delay seeking care until their health is in real danger and when the necessary treatment is more expensive. 

Emergency Services

Emergency services include emergency room visits and emergency transportation, such as by ambulance. A short visit to the emergency room can cost thousands of dollars, and even young, healthy people can have accidents that require expensive emergency room treatment. For instance, treating a broken leg can cost as much as $7,500.  

Hospitalization

Everyone hopes they won’t have to be hospitalized or have inpatient surgery in the coming year, but with the average three-day stay costing roughly $30,000, hospital coverage is essential to people’s financial security. Families shouldn’t have to run the risk that even a short hospital stay could bankrupt them.  

Maternity and Newborn Care

Most women use maternity and newborn care services in their lifetime, and under current law, they can count on it being covered in the marketplace. Before the ACA, 62 percent of people in the individual market had no coverage for maternity care, and the plans that did cover those services usually charged much higher premiums. This made it harder for women to get the care they needed and unfairly put the financial burden of pregnancy and birth on expectant and new mothers.  

Mental Health and Substance Use Disorder Services

Before the ACA, 18 percent of people in the individual market had plans with no mental health coverage and 34 percent had plans with no substance use coverage. Nearly 10 million adults with a serious mental illness and over 20 million people with a substance use disorder need affordable mental health and substance use disorder services like counseling and psychotherapy.

Prescription Drugs

Before the ACA, 9 percent of people in the individual market had no coverage for prescription drugs. Thanks to the ACA, all plans in the individual market must now cover at least one drug in each drug class. Allowing insurers to go back to excluding coverage of whole drug classes would increase the risk that consumers could end up with large out-of-pocket costs because their plan didn’t cover a prescription they need. It would also make it harder for consumers to choose plans that clearly cover the prescription drugs prescribed for them. 

Rehabilitative and Habilitative Services and Devices

Rehabilitative services and devices help people regain skills after accidents and illnesses, like physical therapy to regain full range of motion after shoulder surgery or therapy to regain speech abilities after a stroke. Habilitative services and devices include the same kinds for services — speech, physical and occupational therapy — but they tend to help people develop new skills or maintain existing skills, such as speech therapy for children with autism. Before the ACA, few plans covered habilitative services. Keeping the rehabilitative and habilitative services requirement is key to helping people live full lives. 

Laboratory Services

Laboratory services include the lab tests that doctors depend on to check for risk factors and symptoms like high cholesterol and to diagnose serious illnesses. If these critical services are unaffordable, patients might delay tests, putting their health at risk. 

Preventative and Wellness Services and Chronic Disease Management

Preventative and wellness services include routine care like vaccinations, contraception, and exams that screen for serious health conditions like cervical cancer.  (The House legislation may also affect a separate ACA provision that requires all insurers in both the individual and group markets to provide preventative services and at no cost to enrollees). Chronic disease management includes helping people with long-term conditions such as diabetes and asthma manage their illness and live full lives. Keeping these services available and affordable is critical to preventing the spread of diseases, detecting cancer early, and preventing chronic conditions from worsening. 

Pediatric Services, Including Oral and Vision Care

It is particularly important that children have comprehensive care. Before the ACA, very few plans in the individual market covered dental and vision care for children. Untreated vision and dental problems can hurt children’s school performance.