Once the key phrase of Trump’s presidential campaign, the mantra “repeal and replace” has now become the primary focus of the Trump administration. However, the GOP has yet to decide on a replacement plan for the Affordable Care Act. Instead, some are suggesting repairing the healthcare law by shrinking the services insurers are required to offer on all individual and small group plans. The idea is that reducing the 10 essential benefits could reduce costs and increase plan flexibility, thus create more plan options.
Last week, Seema Verma, Trump’s nominee for administrator of the Centers for Medicare and Medicaid Services, proposed certain services be optional, like maternity services. However, maternity services is not the only coverage requirement that may be targeted by a revision. Since the Affordable Care Act requires services offered on individual plans be equal to business-provided insurance plans, revisions could modify or eliminate the benefits not offered on employer plans.
Per the law, plans must cover “rehabilitative and habilitative services and devices.” However, many employer plans don’t include these type of services. Dania Palanker, an attorney and assistant research professor at Georgetown University’s Center on Health Insurance Reforms, says that “there’s real room for weakening the requirements.”
Mental Health and Substance Use Disorder Services
Plans, subject to the 10 essential benefits, must also “cover mental health and substance abuse services.” Palanker says that the administration “could back off of parity,” meaning that insurers can limit how much they cover certain services compared to others in regards to cost sharing, treatment, and care management.
Oral and Vision Care for Children
Caroline Pearson, a senior vice president at Avalere Health, says that the pediatric oral and vision care requirements could be weakened because they’re not very common in employer plans.
The law, regarding prescription drug coverage, currently requires plans to cover at least one drug in every drug class. According to Katie Keith, a health policy consultant and adjunct professor at Georgetown Law School, the list of required drugs could still shrink.
When it comes to revising the law, the Trump administration has discussed trimming the preventive services that are required without cost sharing. An example would be birth control that doesn’t cost women anything out-of-pocket.
Pregnancy, Maternity, and Newborn Care
Based on research conducted by the National Women’s Law Center, only 12% of individual health plans for women over 30 offered maternity benefits before the enactment of Obamacare. When plans did offer these benefits, it was an added cost and came with a 1-year waiting period or more. That all changed under Obamacare.
Those, who share Verma’s opinion, advocate for optional maternity coverage. Since men and women past a certain age can’t get pregnant, critics argue that they shouldn’t have to pay for services they’ll never use. On the other hand, some people, like Linda Blumberg, a senior fellow at the Health Policy Center at the Urban Institute, say that’s not how insurance is supposed to work.
“We buy insurance for uncertainty and to spread the costs of care across a broad population so that when something comes up, that person has adequate coverage to meet their needs,” Blumberg says.
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