The Biden Administration Can Make Four Simple But Important Changes to Improve Essential Benefits Coverage

Since the Affordable Care Act (ACA) went into effect, the uninsured rate has been cut by half. In addition to making health care more accessible, it also sets minimum standards for coverage and limits the amount anyone can spend out of pocket for those services. This has resulted in improved health and economic outcomes for communities that have for too long been unable to access affordable health insurance options due to systemic racism, classism and other forms of oppression. 

– In the latest open enrollment period, a record-breaking 16.3 million people nationwide signed up for health coverage on ACA Marketplaces.
– States like South Dakota and North Carolina continue to take up the ACA’s Medicaid expansion option, which has extended health coverage to 21 million people nationwide
– This brings the total number of people insured in the United States to a record low and is reason to celebrate. 

But the fight for health justice requires that we honestly assess what needs to change to make health a right for all — and to work towards that change every day. When it comes to minimum standards of coverage, or essential health benefits (EHBs), making progress requires that we work to make EHB standards stronger so that the quality of health coverage improves for all people, whether they get health insurance through Marketplaces, their employer-sponsored plan, or programs like Medicaid.

The good news is that this is something the Biden administration has the power to address in very tangible ways — and now is the time to make some very long overdue upgrades to the EHBs.

In the simplest of terms: EHBs are the health care services that most health plans across the country must cover: services like pregnancy, maternity and newborn care; preventive and wellness care; emergency services; doctor visits; mental health and substance use disorder services, children’s vision and oral care, and more. 

Across the country, nearly 50 million people have health coverage that must comply with the EHBs. Moreover, the ACA also makes large employer plans more affordable by limiting how much people can be charged each year for EHB services that are covered — meaning that nearly everyone who gets their health insurance through their employer benefits from the EHBs in some way.

EHBs were enacted as part of the ACA in 2014, and include 10 categories of care that must be included in insurance policies offered through the ACA’s health insurance marketplaces, small employer health plans, and plans in the individual insurance market in every state. Importantly, states that expand Medicaid must also use the EHBs as the minimum standard of coverage for the newly eligible population. Despite the good intentions when this policy was developed 12 years ago, it has become clear that the benefits covered within insurance plans are not as comprehensive as intended.

This has resulted in big inequities in the services that are covered, leaving far too many people underinsured — resulting in high out-of-pocket costs and deductibles, or people foregoing important, needed care. And there are some critical services, including dental care, that aren’t considered essential and therefore are not covered. This leads to a host of health and economic issues for people, including significant medical debt

A family of four, plus a brown dog, smiles for a photograph in their green yard in a rural setting. From left to right: young child with red hair and bangs, pink stripes; mother in red shirt and sunglasses and armed wrapped around the child; small child in pink is being held by their father; father, in a light t-shirt and jeans, wears a full beard and a baseball cap.
Felicia and her family, who have recently enrolled in the ACA Marketplace, thanks to action the Biden administration took to fix the family glitch.

Take, for example, a family like Felicia’s who is now able to get more affordable health coverage through their state insurance Marketplace thanks to the recent fix of the Family Glitch. While the ACA provides financial assistance to purchase health and dental coverage for her children, Felicia and her husband are left to pay entirely out-of-pocket for their own dental insurance because the current EHB rules don’t include adult dental services. For other families, the lack of clarity on what must be covered by the EHBs might mean their health plan doesn’t cover the cost of addressing the long-term effects of COVID-19, which the medical community is only starting to understand. These gaps and inconsistencies unnecessarily expose people to medical debt and economic uncertainty when seeking care that we can all agree should be considered essential. 

This underscores how important it is that insurance plans provide quality, comprehensive benefits. Because no person should be uninsured — or underinsured — in America. 

The good news is that it doesn’t have to be this way. 

Under the ACA, the Secretary of HHS is required to periodically review EHBs and can update and define them to ensure plans cover quality, comprehensive care in every state. But such updates haven’t happened since the ACA became law over a decade ago — and it’s long overdue.

Community Catalyst is urging HHS to update EHBs to advance health equity, ensuring more people can get the care they need no matter what insurance plan they have. We have also asked the agency to establish a regular, transparent way to review these benefits, which should be community-driven and informed.

EHBs are one of the most significant health policies in the past decade because they finally set a baseline for how comprehensive private insurance plans must be. (Remember when many health plans didn’t have to cover maternity care, resulting in bills for labor and delivery that could bankrupt a family?) EHBs also shape coverage options for people with low incomes and coverage offered when states expand Medicaid.

We are pleased that the Biden administration has committed to advancing equity in the delivery of health and human services. And we were pleased that the administration has solicited the input of the public on what an EHB update should look like. As Community Catalyst highlighted in our official public comments to the administration, now is the time to build on the ACA’s progress by addressing gaps and inconsistencies in coverage to ensure health care plans cover the care people need to stay healthy.

Here are four ways to get there: 

1. Expand Dental Coverage for Adults

HHS has the power to close gaps in coverage by expanding categories defined as “essential” to include dental care for adults. Half of adults with medical debt say at least some of it is due to dental bills, and more than one in three adults report having to delay or forgo the dental treatment they needed due to the high cost of care, which threatens overall health. Everyone should be able to go to the dentist without going into debt.

2. Set National Standard for Maternity Care 

HHS can require that EHBs cover the top clinical guidelines in each benefit category, setting a national standard for maternity care. A 2021 review found extensive differences across state plans, including limits on how many prenatal and delivery services were covered, as well as inequitable postpartum benefits. All people deserve to have the same standards of maternity coverage and care. This is especially important for Black and Indigenous people that have for too long been denied comprehensive, compassionate care, which has contributed  to unconscionably disproportionate rates of preventable pregnancy-related deaths. Updating EHB standards for maternity care should be responsive to the calls of reproductive health, rights, and justice advocates who have highlighted the types of change needed to address the maternity health crisis in our country. 

3. Require Transparency and Accountability on Behavioral Health and Substance Use Disorder Benefits

HHS has a responsibility to require more transparency and accountability about coverage and benefits, including services and treatments related to behavioral health and substance use disorders (SUD), which affects millions of people in the U.S. Behavioral health services are among the most commonly denied claims by marketplace plans, increasing the risk of medical debt or forgoing critical care as people are forced to pay for vital treatment out-of-pocket. Right now, EHB standards for mental health and SUD treatment services are so broad that many marketplace plans don’t cover critical treatment options like methadone — or they require unnecessary and restrictive prior authorizations. The lack of detail provided by health plans also makes it hard for federal agencies to evaluate whether plans are complying with the law. 

4. Prioritize Community Engagement

HHS can establish a permanent, regular process to review EHBs, which must center communities most impacted. That process should begin by listening to a broad and diverse group of people enrolled in Marketplace plans and Medicaid expansion programs — both groups of people who experience the benefits and limitations of EHB standards. HHS should further prioritize robust community engagement throughout the process. Long-standing and systemic barriers to accessing care have resulted in vast racial and economic health disparities; communities that have traditionally had the least access to care should have an outsized voice in this engagement process. 

As more people come to count on EHB coverage standards, the Biden administration can build on its commitment to advancing health equity by improving benefits to ensure coverage allows everyone to get the care they want and need — without going into debt.

In July, led by Community Catalyst, more than 50 groups launched a campaign urging the Biden administration to expand coverage of Essential Health Benefits (EHBs), which have not been updated since the Affordable Care Act (ACA) became law 13 years ago. The groups are calling on the Health and Human Services Secretary Xavier Becerra and Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure to close gaps and inconsistencies, and adopt several health care services into the EHB framework, including oral health care, expanding maternity and postpartum care, gender affirming care, and behavioral health and substance use disorder benefits. Doing so would advance equity amongst communities that disproportionately face barriers to care due to racism, classism and other forms of oppression.