Essential Health Benefits: Gaps and Inconsistencies

The EHBs generally require coverage of Mental health and substance use disorder services, including behavioral health treatment. But EHB standards for mental health and SUD treatment services are so broad that patients’ access to life-saving SUD treatment medications like methadone, buprenorphine, and naltrexone depends on where they live and which health plan they choose. EHB coverage standards should clearly and consistently cover the full continuum of mental health and SUD treatment and services. 

Our country’s maternal mortality crisis is only getting worse and disparities in maternal health outcomes for Black and Indigenous mothers are widening. Lack of clarity around EHB coverage for maternal health care at the federal level means that many patients encounter limits on prenatal and delivery services covered, inconsistent coverage of breastfeeding and lactation services, and unnecessary restrictions on midwives and doula services. This only compounds the racial inequities in access to high quality care for pregnant and postpartum people.  

Transgender and nonbinary (TNB) individuals face significant marginalization in health care settings, including high rates of uninsurance, cost-related barriers to accessing needed care, and direct harassment and discrimination. Moreover, access to gender-affirming care is under direct attack at both the state and federal levels. While the Biden administration has taken steps to clarify protections against discrimination in health care based on sexual orientation and gender identity, EHB standards in many states are silent on coverage for gender-affirming care. Without greater clarity in federal EHB standards, access to this cost-effective and life-saving set of services remains at risk.

Oral health is essential to every person’s overall health and economic well-being. Access to dental care improves health outcomes for costly chronic conditions, reduces risk for adverse birth outcomes, and improves people’s job prospects. Yet, current EHB standards do not include dental coverage for adults, leaving millions of people to pay high out-of-pocket costs, seek care in emergency departments where they incur debt, or live in pain because they can’t afford the care they need. The Biden administration can close this glaring gap now by adding adult dental services to the EHBs. 

Medicaid requires comprehensive and child-specific services in every state through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits, which are considered to be the gold standard. But private coverage differs because the EHBs do not currently define pediatric services beyond oral and vision care. This means that coverage for many children is based on insurance plans that were designed for adults. As many children are likely to transition to private coverage during the Medicaid unwinding, the Biden administration should make sure their access to care remains unchanged. 

The price of prescription drugs is more than 2.5 times higher in the US than in other countries and those costs continue to outpace inflation. This leaves millions of people unable to pay for the medications they need. Coverage of prescription drugs varies in EHB plans from state to state and insurance plan documents aren’t always clear on what’s covered. At a minimum, the Biden administration should align EHB prescription drug coverage requirements with Medicare Part D, ensure coverage of all protected classes of drugs as well as medications opioid disorder treatment and reversal.

The law requires HHS to regularly review and update the EHBs but since the passage of the ACA in 2010, this has never happened. This means that coverage standards that apply to most private insurance plans haven’t kept pace with medical innovation or the needs of the 50 million or more people who have EHB coverage. The Biden administration should establish a permanent process to close gaps in EHB coverage and make timely updates but this can’t happen without the direct engagement of people who struggle to access the care they need. Any EHB review process or advisory body should ensure representation and participation of underserved and marginalized populations, including, but not limited to, Black, Hispanic and other people of color, people with disabilities, members of Tribal communities, and LGBTQ+ people, and other people with relevant lived experiences.