Texas Tech University Health Sciences Center
The Affordable Care Act and Essential Health Benefits

The Affordable Care Act and Essential Health Benefits

the-affordable-care-act-and-essential-health-benefits- image0I think it is fair to say that the Affordable Care Act (ACA) is controversial. That is not being political—just stating what even the most casual observer can detect. In media interviews, lectures and writings, I always try to “stick to the facts” and try to minimize my personal opinion on the ACA. I intend to continue that approach.

But, even with that approach it pays to be realistic and some of the controversial elements of the ACA must be recognized. One of these items is the set of health care service categories that must be covered by certain plans, starting in 2014. These are known as essential health benefits and insurance policies must cover these benefits to be certified and offered in the health insurance marketplace or exchanges.

Essential health benefits include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Why are the essential health benefits controversial? Well, some people, for example, argue they do not need maternity and newborn care. My response is that is not how comprehensive insurance works. Insurance is about the pooling and sharing of risks among a group of people. It’s called community rated. In a community-rated market, the insurer does not calculate premium on the basis of the risk factors attaching to a particular person wishing to purchase an insurance contract, but rather the risk factors applying to all persons within the market as a whole. Thus, in a community-rated market, the insurer evaluates the risk factors of market population, and not those of any one person when calculating premiums. And yes, one pays for access to services that one may never need. Consider this (as the guy on TV says), insurance is a bit like going to Furr’s Cafeteria (with its all you can eat plan)—you pay for access to everything even if you don’t want the liver and onions.