The United States healthcare system is a complex landscape, constantly under scrutiny and subject to ongoing debates about access, affordability, and quality. A cornerstone of recent healthcare reform is the Affordable Care Act (ACA), which introduced significant changes, including the mandate for Essential Health Benefits (EHBs). These EHBs are a set of ten categories of services that most health insurance plans must cover. While the ACA and EHBs represent a major step towards broader coverage, the system is far from perfect and requires continuous evaluation and improvement. This article explores what changes are needed in the United States healthcare program, specifically focusing on the Essential Health Benefits framework and how it can be optimized to better serve the American people.
Understanding Essential Health Benefits (EHBs) and Their Role
The Affordable Care Act stipulated that all non-grandfathered health insurance plans in the individual and small group markets must cover Essential Health Benefits. These benefits are designed to ensure a baseline of comprehensive care and include ten crucial categories:
- Ambulatory patient services: Care received without being admitted to a hospital, like doctor’s office visits and outpatient procedures.
- Emergency services: Treatment for sudden and serious illnesses or injuries.
- Hospitalization: Inpatient care received in a hospital.
- Maternity and newborn care: Care for pregnant women and newborns.
- Mental health and substance use disorder services: Including behavioral health treatment, addressing critical aspects of overall wellbeing.
- Prescription drugs: Medications needed for treatment and management of various health conditions.
- Rehabilitative and habilitative services and devices: Services and devices to help people recover or maintain physical, mental, or cognitive skills.
- Laboratory services: Tests and procedures to diagnose and monitor health conditions.
- Preventive and wellness services and chronic disease management: Crucial for maintaining health and preventing illness, including screenings and vaccinations.
- Pediatric services: Including dental and vision care for children, recognizing the importance of early health interventions.
These ten categories are broadly defined, and the specifics of what’s covered within each category are determined by state-specific EHB-benchmark plans. This benchmark system allows states to choose a representative health insurance plan as a benchmark, defining the scope of EHBs within their jurisdiction.
Flexibility and Evolution of EHB Benchmark Plans
Initially, from 2014 to 2016, states used plans sold in 2012 as their EHB benchmarks. For 2017-2019, plans from 2014 were used. Recognizing the need for greater state autonomy, the Department of Health and Human Services (HHS) introduced more flexibility starting in 2020. States were given options to update their benchmark plans, allowing them to:
- Adopt another state’s 2017 benchmark plan.
- Replace categories within their 2017 plan with categories from another state’s 2017 plan.
- Design a completely new benchmark plan, subject to federal requirements.
This flexibility has continued to evolve. For plan years 2026 and beyond, the options were consolidated, streamlining the process for states to select a set of benefits that would become their EHB-benchmark plan. The goal is to balance national standards with state-level customization to better meet the diverse needs of different populations.
Areas Where Changes are Needed in the E.S. Healthcare Program and EHB Framework
Despite the progress made by the ACA and the EHB framework, significant changes are still needed to improve the US healthcare program and ensure it effectively serves all Americans. Focusing on the EHB aspect, several key areas require attention:
1. Standardization vs. State Flexibility: Finding the Right Balance
While state flexibility in defining EHB benchmarks can be seen as a strength, allowing for customization to local needs and preferences, it also creates complexity and potential disparities. The level of coverage can vary significantly from state to state, leading to situations where individuals in different states have access to different levels of essential care, even under the ACA.
Needed Change: Explore a greater degree of national standardization for EHBs. While maintaining some state flexibility might be desirable, establishing clearer federal minimum standards within each of the ten categories could ensure a more equitable baseline of coverage across the country. This could involve defining specific services or treatments that must be included in each EHB category nationwide, reducing variations driven by differing state benchmarks.
2. Addressing Gaps in Essential Health Benefits Coverage
The ten EHB categories are comprehensive, but some argue that they still leave gaps in coverage for certain crucial services. For example, while pediatric dental and vision care are included, routine dental and vision care for adults are notably absent from the mandated EHBs (though starting in 2027, routine non-pediatric dental services can be included). Long-term care services, critical for an aging population, are also not explicitly mandated as EHBs.
Needed Change: Re-evaluate the scope of EHBs to determine if adjustments are needed to reflect current healthcare needs and priorities. Consider expanding the categories or clarifying the definitions within existing categories to ensure coverage for services like:
- Adult Dental and Vision Care: Routine dental and vision care are essential for overall health and preventative care. Including these as mandated EHBs would address significant gaps in coverage and improve health outcomes.
- Long-Term Care Services: As the population ages, the need for long-term care is growing. Exploring ways to incorporate some level of long-term care coverage within EHBs, or at least facilitate access to affordable long-term care options, is crucial.
3. Ensuring Adequacy and Scope of Benefits within EHB Categories
Even within the defined EHB categories, the actual scope of benefits can vary based on the chosen benchmark plan. Some benchmark plans might offer more comprehensive coverage within a category than others. This can lead to situations where individuals are technically covered for EHBs, but the depth and breadth of that coverage might be insufficient to meet their actual healthcare needs.
Needed Change: Implement mechanisms to regularly review and update the adequacy of coverage within each EHB category. This could involve:
- Regularly updating benchmark plans: Ensuring that benchmark plans are based on more recent and comprehensive insurance plans, reflecting advancements in medical treatments and standards of care. The current system relies on plans from several years prior, which might not fully represent current best practices.
- Establishing minimum coverage standards within categories: Beyond just defining categories, set minimum standards for what must be covered within each category. For instance, within “mental health services,” specify types of therapies, levels of care, or conditions that must be covered to ensure meaningful access to mental healthcare.
4. Focusing on Affordability and Accessibility of EHBs
The promise of EHBs is to ensure access to essential healthcare services. However, coverage alone does not guarantee affordability or accessibility. High deductibles, co-pays, and other cost-sharing mechanisms can still create significant financial barriers, even for individuals with EHB-compliant plans. Furthermore, provider networks, particularly in certain specialties like mental health, can be limited, making it difficult to access care even with insurance coverage.
Needed Change: Address the affordability and accessibility challenges related to EHBs. This includes:
- Strengthening cost-sharing reduction programs: Enhance subsidies and programs that help low- and moderate-income individuals afford the out-of-pocket costs associated with EHB coverage.
- Expanding provider networks: Implement policies that incentivize or require insurers to maintain robust provider networks, particularly in underserved areas and for essential specialties like mental health and substance abuse treatment.
- Standardizing and simplifying plan designs: Reduce the complexity of health insurance plans and cost-sharing structures to make it easier for consumers to understand their coverage and potential out-of-pocket expenses.
5. Improving the EHB Benchmark Plan Update Process
While the HHS has introduced flexibility in the EHB benchmark plan update process, ongoing improvements are still needed to ensure it is efficient, responsive, and data-driven. The process should be less burdensome for states while also ensuring that updates lead to meaningful improvements in coverage and reflect the evolving healthcare landscape.
Needed Change: Continue to refine the EHB benchmark plan update process by:
- Providing clearer guidance and technical assistance to states: Simplify the process for states to update their benchmark plans and offer resources and expertise to support them in making informed decisions.
- Incorporating data and evidence-based practices: Encourage states to use data on healthcare utilization, costs, and health outcomes to inform their benchmark plan updates, ensuring that changes are driven by evidence and aimed at improving population health.
- Promoting transparency and public input: Enhance transparency in the benchmark plan selection process and ensure opportunities for public comment and stakeholder input, allowing for broader perspectives to be considered.
Conclusion: Towards a More Effective and Equitable Healthcare Program
The Essential Health Benefits are a critical component of the US healthcare program, aiming to guarantee a minimum level of coverage for essential services. However, to truly achieve the goals of access, affordability, and quality, ongoing changes and improvements are necessary. By focusing on standardization, addressing coverage gaps, ensuring adequacy of benefits, improving affordability and accessibility, and refining the benchmark plan update process, the United States can move towards a healthcare program that better serves all its citizens. Further research, policy discussions, and collaborative efforts are crucial to implement these needed changes and build a more effective and equitable healthcare system for the future.
