5 Things to Know About Essential Health Benefits

As House Speaker Paul Ryan, R-Wisconsin, and President Donald Trump endeavored to round up enough Republican votes to pass the American Health Care Act (AHCA) in the House of Representatives this week, a major sticking point for some reluctant GOP legislators was the inclusion of the Affordable Care Act (ACA)’s essential health benefits in the replacement bill. Reports indicate that the essential health benefits requirement will be cut from the bill that will go to the House for a vote today.

Here are 5 things to know about essential health benefits.

1. What are essential health benefits?

One provision of the ACA was the requirement that all marketplace insurance plans provide coverage for 10 types of services defined as “essential.” According to HealthCare.gov, those essential benefits were: ambulatory services; emergency services; hospitalization; pregnancy, maternity, and newborn care; mental health and substance use services; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

2. Why are they on the chopping block?

The House Freedom Caucus, a conservative group of 30 House members led by Representative Mark Meadows, R-North Carolina, denounced the initial bill as “Obamacare-lite” and vowed that they would not vote for a replacement that included components it considered to be an overreach of government authority, including the essential benefits requirement. AHCA will fail if just 23 Republicans vote against it, since it is assumed it will garner no votes from Democrats, so securing votes from Freedom Caucus members is essential to its passage.

3. What would happen if they are eliminated?

Insurers could likely sell plans with less expensive premiums if the essential health benefits were no longer required, but costs would rise for the patients that need those services. A Health Affairs blog post presents the example of no longer including maternity coverage, which “might lower premiums by $8 to $14 per month, but would dramatically raise the cost of coverage for women in child-bearing age.” Insurers could then “cherry pick” the market by offering plans with less extensive coverage for healthier people, while people with more healthcare needs would have to purchase a more expensive plan.

4. If the bill is passed in the House, are essential health benefits gone for good?

AHCA, if passed, will proceed to the Senate, where experts say the bill will have a tougher time. There are 52 Republican senators, so if just 2 vote against it the bill cannot achieve the majority it needs. Another wrinkle is that the AHCA is being passed through the budget reconciliation process, which only allows legislative changes that directly affect the federal budget. Congressional experts told Vox that there is a solid argument that this provision violates the rules of budget reconciliation, but the GOP could find a way to maneuver around it.

5. Who is fighting against the repeal of essential health benefits?

Predictably, Democratic legislators have strongly objected to the proposition of cutting essential benefits, arguing that Americans would be left without affordable coverage for these services. House Minority Leader Nancy Pelosi, D-California, voiced concerns about women’s access to maternity coverage:

Stripping maternity coverage in #TrumpCare is a pregnancy tax, pure and simple.

— Nancy Pelosi (@NancyPelosi) March 23, 2017

Groups of medical professionals have also expressed their opposition. Upon news of the delayed vote, the American College of Physicians released a letter urging Congress to “put aside this fundamentally flawed bill and go back to the drawing board to work with us and other patient advocates.” They said that any future reform efforts should not only maintain but build upon the existing requirements for essential benefits coverage.