House Republicans, looking for a deal to secure their health care legislation, may scrap one of the Affordable Care Act’s most important consumer protections: requiring individual health insurers to cover ten essential health benefits.
The benefits are:
- Pediatric services, including oral and dental care
- Pregnancy, maternity and newborn care
- Outpatient care
- Emergency services
- Prescription drugs
- Mental health and substance abuse services
- Laboratory services
- Rehabilitative services
- Prevention services and chronic disease management
Without the mandatory coverage of essential benefits, the health law’s limits on out-of-pocket spending would be “essentially meaningless” because it applies only to those essential services, according to a blog post on Thursday by Timothy Jost, an Emeritus law professor at Washington and Lee University.
The health law’s ban on annual and lifetime coverage limits also applies only to essential benefits, meaning they too would be eliminated under the still-evolving GOP bill.
“That means insurers could again effectively cap the amount they would pay for a consumer with a high-cost or long-term health need such as cancer treatment,” according to a blog by Sarah Lueck, a senior policy analyst at the liberal Center on Budget and Policy Priorities.
U.S. Rep. Mark Meadows, a North Carolina Republican who is chairman of the conservative Freedom Caucus, told Fox News late Wednesday that he had reached “an agreement in principle” with President Donald Trump on changes that could earn more conservative support. Many want to end the federal regulations that require insurance plans cover the essential benefits, which they say are too costly.
The benefits are a popular part of the Affordable Care Act for many consumers. Before the health law was passed, the market for individual coverage sold outside the workplace was a treacherous environment for consumers. High coverage denial rates, lean benefits and premiums subject to frequent increases were the norm.
Before the Affordable Care Act, plans had basically no national rules governing what must be the covered, so many offered limited protections.
Plans had basically no national rules governing what must be the covered, so many offered limited protections.
A government report in 2011 found that 62 percent of individual plan members had no maternity coverage, 34 percent lacked coverage for substance abuse treatment, 18 percent had no mental health services and 9 percent lacked coverage for prescription drugs.
The Affordable Care Act engineered a complete makeover of individual and small group insurance through a series of changes designed to make the coverage more generous, accessible, affordable and transparent.
The law required all individual and small group health plans to cover a list of “essential health benefits,” including outpatient care, like doctor visits; emergency room services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative services; laboratory services; preventive and wellness services and pediatric services.
The mandatory coverage encouraged competition based on price and quality said a blog post on Thursday by Jeanne Lambrew, senior fellow The Century Foundation, a left-leaning think tank.
“Essential health benefits guarantee to the parent of a child with a developmental disability that his therapy will be covered; to a woman that she will not have to pay for each of her prenatal care visits; and to a daughter with a father with dementia that his mental health care will be covered,” Lambrew wrote.
Eliminating the essential health benefits “would make this damaging bill even worse,” said a statement from Bruce Siegel, President and CEO of America’s Essential Hospitals, which provide care to a large share of low-income patients. “It could leave countless people with too little coverage to meet their health care needs and drive higher rates of uncompensated care at hospitals already struggling to cover their costs.”
The last-minute change will doom the legislation if it makes it to the Senate, Sen. Patti Murray, D-Wash., said on the Senate floor Thursday morning.
“Republican leaders know just as well as Democrats do that measures to take away these critically important protections can’t survive the reconciliation process and could never get 60 votes in the Senate,” said Murray, ranking member of the Senate Health, Education, Labor & Pensions Committee. “They are simply trying to sell conservatives a bill of goods today in the rush to jam this through – but the more they scramble, the more harmful this bill gets for patients and families.”