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Tuesday, April 25, 2017

Repealing Essential Health Benefits Means Only the Wealthy Can Afford Good Coverage

Lydia Mitts

Associate Director of Affordability Initiatives

Update (5/4/17): The House or Representatives passed a bill, the American Health Care Act (AHCA), that allows states to opt out of requiring that health plans cover the Essential Health Benefits (EHB).  


EHB requirements ensure that everyone in the individual and small group health insurance markets has access to comprehensive coverage that actually covers the services they need. 

Allowing states to waive the EHB requirements would leave millions without any affordable health care options, forcing them to pay out of pocket for needed care or go without care all together.

What are Essential Health Benefits and why do they matter?

The Affordable Care Act (ACA) required all plans to cover 10 categories of benefits:  

  1. Ambulatory patient services (outpatient services, like doctors’ visits and urgent care)
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices (for example, care that helps patients with physical or developmental disabilities gain, maintain, and improve skills necessary for daily functioning) 
  8. Laboratory services (like blood work, x-rays, and medical scans)
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Because of EHB requirements, people with mental health or substance abuse disorders have the peace of mind of knowing that their plan must cover their needs and that their coverage for these mental health services must be as comprehensive as their coverage for medical and surgical services. Women can rest assured knowing that they will have maternity coverage when they become pregnant. People with developmental and intellectual disorders, like autism, benefit from habilitative services that help them learn, keep, or improve functional skills that help them achieve their personal ambitions. Millions of people have benefited from gaining coverage from these essential services under the ACA.

What would happen if the Essential Health Benefits are not required?

Plans would become very skimpy and once again discriminate against people with pre-existing conditions. Without a requirement to cover essential health benefits, two things would happen: 1) most insurers would stop offering comprehensive plans for fear of attracting people with high health care needs; and 2) the few plans with coverage for services like maternity care, mental health and substance use treatment, habilitative treatment, and even prescription drugs would become radically more expensive.

Because only people who need these services would purchase a plan that covered them, insurers would have an incentive not to sell such plans at all or to make them incredibly expensive. While on paper, there might still be a ban on insurers discriminating against people with pre-existing conditions, in practice, insurers would be discriminating against people with chronic conditions left and right. Not selling comprehensive coverage or making that coverage exorbitantly more expensive than plans that only cater to the needs of people in perfect health is discrimination against people with pre-existing conditions.

In total, it would be a return to the days before the ACA where it was it nearly impossible for people to find affordable coverage that actually covered their health care needs. Before these essential health benefits were in place, millions of people purchasing coverage on their own couldn’t get coverage for critical care:

  • More than 3 in 5 people didn’t have maternity coverage.
  • 1 in 3 people didn’t have coverage for substance use treatment
  • Close to 1 in 5 people didn’t have coverage for mental health care.
  • Almost 1 in 10 people didn’t have any coverage for prescription drugs (despite 60 percent of people in this country needing at least one medication each year).

Caps on how much people have to pay out-of-pocket would vanish. The ACA placed a limit on the maximum amount of money anyone has to pay out of their own pocket for care in one year, called an out-of-pocket maximum. This year, the protective cap ensures that people with serious medical problems never have to pay more than $7,350 in a year for covered care, and families never have to pay more than $14,700. 

This protection only applies to covered essential health benefits. If the essential health benefits goes away, so does this vital financial protection. This means that anyone purchasing a plan in the individual market would no longer be protected from exorbitant out-of-pocket costs and insurers could offer plans with extremely high deductibles and cost-sharing (e.g., copayments, coinsurance) – shifting more of the cost of care to consumers. 

What would a plan look like without the Essential Health Benefits? 

To get a better idea of what plans would and would not cover if essential benefit requirements went away, we looked at some top selling short-term health insurance policies sold in a number of states – policies that you can buy for up to 9 months and that do not have to follow the ACA. 

Here’s what these plans commonly DO NOT cover:

  • outpatient prescription drugs
  • no mental health or substance use services
  • no prenatal care or delivery services
  • limited or no well-baby care 

Several plans limited coverage for emergency room visits unless they resulted in an admission. They also covered barely any preventive care.  

While those exclusions where advertised to shoppers through plan comparison tools, shoppers would have to read the fine print to see other dangerous exclusions hidden in small print, such as:

  • No coverage for physical, speech, or occupational therapy
  • No treatment for injuries from sports
  • No treatment for self-inflicted injury or sickness
  • Exclusions for orthopedic treatment
  • No treatment for any congenital condition
  • Six-month wait before certain procedures, like tonsillectomies 
  • No treatment for chronic pain, AIDS, or immunodeficiency orders
  • No treatment for kidney or end-stage renal disease
  • No treatment or diagnosis for allergies
  • No treatment for joint replacement (unless related to a covered injury)
  • No services or supplies for smoking cessation
  • No organ or tissue transplants
  • No weight loss/obesity treatment or surgery
  • No treatment for acne or moles

At the end of the day, the equation is simple: Do we want a health care system that guarantees that every woman is able to afford maternity coverage when she is pregnant, that every child with a development disability is able to afford the therapy they need to fulfill their dreams, that every person struggling with addiction, like opioid use, can get the treatment they need, and that every person with a chronic condition is protected against discrimination? If so, we need the essential health benefits. 

This media teleconference, hosted by the National Partnership for Women & Families, discusses how ACA repeal attempts, including the Republican-led House bill, threaten access to essential health benefits like maternity care, treatment for substance use disorders and other mental health services, and life-saving prescription drugs.​

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