What the GOP bill could mean for 'essential health benefits'

Eliminating or reducing required health insurance benefits, now part of the Republican bill to repeal the Affordable Care Act, also threatens to kill the ACA's annual and lifetime limits on patients' costs, which was enacted to prevent bankruptcies due to medical costs.

Late Thursday night, House Speaker Paul Ryan released an amendment that would leave it up to states starting in 2018 which, if any, of these benefits have to be included in plans sold to people receiving tax credits to buy their insurance. About 85% of people who buy their insurance on the Affordable Care Act (ACA) exchanges get tax credits. This, the Speaker's office said, "will help lower costs and expand choices."

The limits on out of pocket costs only apply to the ACA-required 10 essential health benefits, which include prescription drugs and hospital care. So eliminating the benefit requirement makes the limits "essentially meaningless," says health care legal expert Tim Jost.

Currently, these benefits must be covered in employer-provided insurance and plans sold on the exchanges in states that use Healthcare.gov, while states that operate their own exchanges can have slightly different requirements. Plans for people who gained coverage under the ACA expansion of Medicaid also have to include these benefits.

In addition to prescriptions and hospital care, marketplace plan benefits also include:

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• Pregnancy, maternity and newborn care

• Mental health and substance abuse disorder services

• Rehab services and devices for people with disabilities

• Preventive and lab services

• Dental care for kid

The latest amendment to the American Health Care Act would dedicate an additional $15 billion to the Patient and State Stability Fund (PSSF) for services covered in essential health benefits including maternity, mental health, and substance abuse care.

The money would help, says National Council for Behavioral Health CEO Linda Rosenberg, but it doesn't come close to offsetting the $880 billion cuts planned for the Medicaid program.

"This is a grant and that’s an entitlement," says Rosenberg. "We don't do that with breast cancer - tell people you have to go to a place for treatment that got a grant for five years."

Hal Lawrence, a physician who is CEO of the American Congress of Obstetricians and Gynecologists, is also far from satisfied with the late night change.

“We support maternity coverage for all women in all insurance plans, regardless of who a woman works for or where she lives," says Lawrence. "This fund is not a solution and does not, in any way, mitigate the assault on women's health by returning maternity coverage to the vagaries of state politics."

"Instead of continuing to make a bad bill worse," Lawrence says Congress should start over again to come up a bill that improves health and reduces costs.

The  House's Freedom Caucus, a group of conservative Republicans, had been pushing for language that would eliminate these required services, but House leaders originally said it couldn't be done under the special procedures through which the legislation is being moved through Congress. These require only 51 votes and don't allow for a Democratic filibuster. Wednesday night, Sen. Mike Lee, R-Utah, said the Senate parliamentarian had told him the insurance provisions would not necessarily violate those budget procedures.

Many consumers concerned about their high ACA premiums often complained that their plans included coverage they said they neither needed nor wanted. Women past childbearing years found their maternity and birth control coverage particularly galling or at least laughable, but some experts say such coverage costs need to be spread across all people to keep premiums reasonable.

"This notion that people can buy the plan they want" is flawed, says Linda Rosenberg, CEO of the National Council for Behavioral Health, which represents mental health and addiction treatment centers. Young people would only buy catastrophic coverage and the pool of people with regular insurance would be much sicker and costs would be prohibitively high, she says.

Health care economist John Goodman, however, says "it would be some help if insurers could have more flexibility in what they offer." Goodman, who helped draft one of the Republican ACA alternatives in Congress, says the required health benefits "force everyone to pay more money" for plans that cover services they may not need, such as for a very premature baby.

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Along with keeping Medicaid intact, Rosenberg says the requirement that plans cover mental health and addiction treatment needs to stay in any bill that passes Congress. She says reducing the number of people covered by Medicaid and/or the coverage in Medicaid and ACA plans — as the Republicans' American Health Care Act would — threatens the ability of people suffering from mental health or addiction disorder to work and stay out of prison.

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That describes the risk Samuel Hedgepeth says he would face if he lost his mental health and addiction coverage. He says he self-medicated for his bipolar disorder beginning at age 13 with alcohol and drugs including cocaine, heroin and other opioids. It wasn't until he got Medicaid in Maryland last year that he got treatment for his mental illness, despite 10 years in prison. He says he suffered from anger, paranoia and suicidal thoughts.

"My alcohol and my drug addiction —  that was my way of coping"  says Hedgepeth, who lives in Hyattsville, Md. "Your body starts craving it, and you're willing to do anything to satisfy that obsession."

Eliminating the required health benefits could also jeopardize more moderate Republicans' votes even if it attracts conservatives.  Rep. Peter King, a moderate New York Republican, went from a "no" vote to undecided after talking to President Trump, but then said he was closer to "no" after the essential health benefit plan surfaced.

Many moderate members also "ran by saying their top priority was addressing the opioid epidemic, the worst drug crisis in U.S. history," says Meaghan Smith, a spokeswoman for a coalition of ACA supporters known as the Protect Our Care Campaign. Eliminating essential health benefits "will be devastating for people throughout the country trying to fight the opioid epidemic and it will be political disaster for these members of Congress."

As for screening tests, Goodman says "preventive medicine doesn’t pay for itself," adding that many tests are "very controversial."

If cancers aren't caught early because people are either uninsured or their plans don't have to cover preventive health screenings, doctors and other health experts say cancer rates and deaths will increase. The Kaiser Family Foundation has reported 36% fewer uninsured women had a mammogram in the last two years, and uninsured women were 30 to 50% more likely to die from the disease. Women who lacked insurance were also three times less likely to have had a Pap smear in the last three years and had a 60% great risk of late-stage cervical cancer.

Cervical cancer, says Lawrence, "is basically it’s a preventable cancer." The later cancer is diagnosed, however, the greater the risk of death.

"It’s a horrible idea that takes away women’s access to preventive and maternity care," Lawrence says of the AHCA.  "What (members of Congress) will do is increase illness, pregnancy complications, cancer and death. Sadly, the AHCA takes us back to well before the ACA."