Skip to content

Business Groups, Consumer Advocates Draw Lines In The Sand About Essential Benefits

The essential health benefits (EHBs) countdown is on for 2016.

That’s when this provision of the Affordable Care Act, which sets out 10 specific health services that must be covered by plans sold on the exchanges, will likely be  reviewed by the Department of Health and Human Services. Business interests and consumer advocates are already making their positions clear — the former pushing for greater consciousness of premium costs and the latter looking to safeguard consumers’ coverage.

During a July 21 Capitol Hill briefing, members of the Affordable Health Benefits Coalition, a business interest group including the U.S. Chamber of Commerce and the National Retail Federation, said they would push to reshape essential benefits, arguing that current regulations have led to unaffordable hikes in insurance premiums.

Current policy requires plans cover emergency services, pre- and post-natal care, hospital and doctors’ services, and prescription drugs, among other things. The rule lets states decide how specifically to interpret those categories.

“What I hope is that they tear down the existing EHB and rebuild it from the bottom up,” said Neil Trautwein, employee benefits policy counsel for the National Retail Federation, in an interview. Trautwein said the group would lobby both members of Congress and White House officials starting in 2015, in addition to making sure this issue is part of congressional candidate’s talking points in November’s midterm elections.

But consumer advocates will be working on a separate path in the months ahead.

Cheryl Fish-Parcham, private insurance program director for Families USA, told KHN that though the organization has not yet worked out details of its strategy, it will work alongside groups such as the National Women’s Law Center and the Georgetown Center for Children to make sure that most of the current health benefit requirements are maintained.

“People need to be cautious about thinking of the cost of premiums without thinking about what you’re getting for the premiums,” she said.

For instance, before federal regulations required plans to cover maternity care, people would purchase plans that didn’t cover pregnancy-related needs – often not realizing so until too late, she added. Similar situations also arose with plan purchasers who didn’t realize they would need coverage for mental health care or substance abuse, areas current EHB policy mandates be covered.

“Those really leave you up a creek,” she said.

Meanwhile, Trautwein did not list benefits that should be cut, suggesting instead that groups such as the Institute of Medicine determine what is really essential. Insurance plans, he added, “are perfectly capable” of providing benefits without being required to do so through federal regulation.

“This may be a question of setting a budget for the package and then see how much fits in,” he said, adding that premium cost “bears revisiting.”

But looking too closely at premium cost could have other ramifications, Fish-Parcham said. For instance, regulations that lead to reduced premiums could result in higher deductibles, leaving plan users “very vulnerable.”

Instead of looking at cutting benefits themselves, she added, policymakers should look at cutting the overhead costs that go into each benefit – for instance, the costs of health care facilities or insurers’ administrative fees.

“There are a lot of areas to look at for cost control in the future,” she said.