People will die if HHS weakens requirements for essential health benefits

People will die if HHS weakens requirements for essential health benefits
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Too often, the millions of Americans who are living with chronic conditions are overlooked or singled out in our health-care system. With the advent of the Affordable Care Act (ACA), covering these patients and making their medications affordable became a priority.

Through constant attacks on the ACA, whether to repeal the individual mandate or denying cost sharing reduction payments, it is crucial that the focus remain on patients to ensure that access to care is not compromised.


Unfortunately, pending at the Department of Health and Human Services (HHS) is a proposed rule that would weaken the essential health benefits (EHBs) every insurance plan must cover that could ultimately jeopardize health coverage and access to prescription drugs for vulnerable patients.


The ACA identified ten essential health benefit categories, including prescription drug coverage, ambulatory care, treatment for mental health and substance abuse disorders, and preventative services. These requirements ensure that all patients, regardless of income, health, or any other condition, would be able to access care.

This is especially critical to patients with pre-existing, chronic conditions who face unique barriers to care including access and cost. In fact, they’re so important that the I Am Essential coalition recently sent a letter to HHS signed by 138 patient groups urging the administration not to undermine these critical patient coverage protections.

Unfortunately, what HHS is proposing would open up the potential for states to significantly pare down essential health benefits, especially for prescription medications. The administration is contemplating a mechanism to establish “a national benchmark plan standard for prescription drugs.”

Allowing the federal government to specify the minimum number of medications plans are required to cover, or even allow them to develop their own list of covered drugs through a national drug formulary, raises a red flag. If HHS were to implement such changes, it could severely restrict access to prescription drugs and essentially ration care. This is unacceptable for all Americans, especially for the millions living with serious and chronic conditions who rely on medications that are prescribed to them by their providers to keep them healthy.

Additionally, the proposed rule includes a provision that redefines how a state determines their essential health benefits. For example, states could choose a benchmark plan from another state; adopt the prescription coverage from one state and mental health coverage from another; or select a totally new benchmark plan.

This could lead to deterioration of coverage for patients by states adopting the least comprehensive coverage for each benefit category. This would be a slippery slope and could ultimately lead to health insurance plans that provide very little coverage and translate into higher cost-sharing and out-of-pocket expenses for patients.

To avoid these harmful consequences, the final rule must ensure that the patient coverage protections and prescription drug access provided by the ACA are preserved.

Moving forward, HHS must strive to continue to enforce the ACA’s strong nondiscriminatory provisions. Some insurers still design plans that are discriminatory and limit patient access. Beneficiaries continue to encounter plans that lack meaningful formulary coverage for prescription medications, engage in adverse tiering, have high cost-sharing and burdensome utilization management requirements such as extensive and/or unwarranted prior authorization and step therapy requirements.

Beneficiaries also still face mid-year formulary changes, and can have their medications switched for non-medical reasons. Regulations and guidelines are worthless if they are not enforced.  As HHS moves enforcement to the states in the name of state flexibility, it is questionable if all states have the resources or will to fully protect patients.  

Since the ACA was implemented, we have made great advances to guarantee that patients have access to the medications they need and that patients diagnosed with complex conditions such as bipolar disorder, epilepsy, schizophrenia, and HIV are not singled out to pay more. However, all the progress gained is in danger of being lost if HHS moves forward with its proposals to weaken the essential health benefits.

Carl Schmid is deputy executive director of The AIDS Institute, and co-leads the “I Am Essential” Coalition, a broad group of patient and community organizations representing millions of patients and their families.