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What's at risk in GOP plan to dump essential benefits?

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Posted at 1:19 PM, Mar 24, 2017
and last updated 2017-03-24 13:19:25-04

CINCINNATI –  Maternity care, prescription drugs, a trip the emergency room – these are just a few of the benefits health insurers could choose to dump coverage for under the latest plan to overhaul the Affordable Care Act.

Eliminating a requirement for health insurers to cover 10 essential health benefits was among several last-minute changes floated late Thursday as Republicans hustled to gain support for a plan to repeal and replace the nation’s health care law.

As the debate continues, here’s a look at why essential benefits matter and what the changes could mean for you and your family.

What are the 10 essential benefits?

Under the Affordable Care Act, insurance companies selling plans through the online marketplaces to families and individuals are required to cover the same set of benefits. They include:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Why were essential benefits included in the ACA?

Prior to the ACA, health insurers could sell cheap policies that covered few conditions and medical services. But critics of those plans argued they placed too much risk on the consumer -- exposing them to financial ruin if they, for example, were diagnosed cancer or a costly chronic illness.

Is there an upside to eliminating them?

The crafters of the GOP plan say dumping the benefits requirement would boost consumer choice among health insurance policies and lower costs.

For example, a single man could purchase a plan for himself that didn’t include maternity coverage. And because his policy covers less, it would likely be less expensive.

What’s the downside to dumping them?

Opponents of the plan say it’s a step backward to pre-ACA days when insurers could side-step covering the sickest people and skimpy insurance plans could force people into bankruptcy.

States could get to decide

Under the GOP plan, starting next year states would be able to decide what – if any – benefits must be covered by insurers selling plans through the marketplace, according to Kaiser Health News.

Can essential benefits really be cut?

The proposed changes to the ACA are being pursued through a process known as budget reconciliation – which means that any changes made must be related to federal spending. Therefore, any changes to essential benefit requires must lower federal spending in some way.