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ASHINGTON — As Republicans frantically scramble to find votes to pass their health care bill, the most important debate may be about one issue: essential health benefits.

That is the Affordable Care Act’s requirement that health insurance plans sold to individuals and small groups cover 10 types of services, from prescription drugs to substance abuse treatment to maternity care.

That requirement was never as widely discussed or debated as Obamacare’s individual mandate or Medicaid expansion. But it is now central to understanding the debate in Congress.

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The most conservative lawmakers in the House, who say they have enough votes to block the bill unless GOP leadership meets their demands, want that requirement gone. They say it makes insurance unaffordable, by mandating everybody buy broader coverage.

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The White House and House leaders are reportedly open to making that change, though it would raise a whole host of other questions.

Here’s what you need to know, with some help from outside experts and the reporters tracking the debate on Capitol Hill.

Why are essential health benefits important to Obamacare?

EHBs (as wonks would call them) were necessary to making Obamacare work as its authors intended. They ensured that people would have comprehensive coverage, and that the law would be able to provide other protections, such as preventing insurers from discriminating against people with preexisting conditions.

Some experts worry the market wouldn’t work if EHBs are repealed in the Republican bill. Insurers would be allowed to offer much skimpier coverage. Healthy people, who aren’t as worried about getting sick, would gravitate toward that skimpier coverage because it’s cheaper. Sick people would buy more generous coverage, because they need it.

That could send the market into a “death spiral” — insurers raise the price of the more generous coverage sick people are buying, because they are more expensive to cover. That could eventually drive coverage out of reach for many of them.

Why is this a debate?

Republicans have long railed against EHBs, portraying them as a government mandate that drove up costs and forced people to buy coverage they didn’t want or need.

But they were not repealed in the Republican health care bill, as it was originally released. The official explanation was that Congress could not repeal the requirement under the complex Senate rules they are using to avoid a Democratic filibuster in the Senate. The gist of those rules is that every provision in the bill must have a budgetary effect. It had been widely assumed that an insurance rule like EHBs doesn’t qualify.

But the most conservative lawmakers weren’t satisfied with that answer and have sworn to vote against the bill unless some of their demands, including repealing EHBs, were met. One group of those lawmakers, the House Freedom Caucus, has claimed to have enough votes to block the legislation.

Reports are leaking out Wednesday evening that the White House and House leaders are now open to including EHB repeal in the bill.

So what now?

It’s hard to say. There are so many variables. But the tea leaves right now suggest that House leaders know they can’t pass the bill unless they repeal EHBs. The Freedom Caucus is dug in to stop the legislation otherwise.

But if the House makes that change, it could make the bill harder to pass in the Senate, especially if the change is projected to increase the total cost of the bill or if it leads to more people being considered uninsured.

Then you have the real-world consequences, if the bill actually became law. EHBs required health plans to cover mental health and addiction services for the first time, right as the opioid crisis rose to the top of the national consciousness. Drug makers could have fewer insured customers if drug coverage is no longer required. If EHB repeal really does lead to a death spiral in the insurance market, that’s a whole different set of problems. Each state would be left to define their own coverage requirements, which could set off 50 new debates across the country.

It’s a lot for Republican leaders, their policy advisers, and the rest of us to untangle. The House vote on the bill, as of now, is still set for Thursday.

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  • Repealing the EHBs may add cheaper coverage options to the Affordable Care Act, but for clarity they should keep the ACA levels of coverage with their names (Brass, Silver, Gold and Platinum), and just add a few more levels with fitting names such as Tin, Lead, Stone, and Dirt.

    • Dennis, note that some the consequences of removing EHB are more insidious than appear superficially.

      As with a lot of individual insurance issues, at least half of people, and half of insurers, will game the system as best they can, and this forces serious failures (really high premiums), even for people not gaming the system. Also all insurers wind up having to game the system.

      (You really kind of have to think through various economic mechanisms, and often they’re not obvious, so you even have to have the failures pointed out to you. Then if you have a quantitative grip on insurance pools and such, you can confirm each pointed-out problem.)

      This nice recent NY Times Upshot article does a good job, using many consulted experts, to point out the problems resulting from no EHB, even for people looking to by full EHB insurance:

      https://www.nytimes.com/2017/03/23/upshot/late-gop-proposal-could-mean-plans-that-cover-aromatherapy-but-not-chemotherapy.html

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