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The Essential Health Benefit: Could a 'minimal' benefit vanish altogether?

January 25, 2012
by Ron Manderscheid, PhD
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Reliance on small-business plans as EHB standard could lead to reductions in treatment

Just a few short weeks ago, I wondered in an earlier piece whether the essential health benefit might in fact become a “minimal” health benefit. At that time, I was very concerned about the recent Institute of Medicine report to HHS, which recommended that the Department use a typical small-business health insurance benefit plan as the standard for defining the Essential Health Benefit (EHB) required by the Affordable Care Act (ACA).

While the ACA requires the EHB to include benefits for mental health and substance use care, and these benefits must be at parity, small business plans often do not include behavioral health benefits and when they do, they are almost never at parity. Hence, small business plans are inadequate as a standard for the EHB.  

The EHB is important because it will be used not only as the “floor” health insurance plan for the state Medicaid expansion (providing health coverage for those with incomes up to 133% of the Federal Poverty Limit), but also as the “floor” plan for plans offered in each state’s health insurance exchange (providing coverage with subsidies for those with incomes from 134 to 400% of FPL).

And, of those who will be newly eligible for coverage, we know that 10.5 million have an existing mental health or substance use condition, and of these:

  • virtually all to be covered in the state Medicaid expansion will require services equal to those currently provided to consumers in the public mental health/substance use care systems.
  • most covered by the state health insurance exchanges will need that same level of care as well.

With the December 15 release of the Essential Health Benefit recommendation from HHS, I became even more concerned because HHS did not develop a standard for the Essential Health Benefit. Instead, HHS recommended that each state establish its own EHB by choosing among four existing plans:

  • the Federal Employee Health Benefit Plan (FEHBP)
  • the state employee health benefit plan
  • the health benefit plan of the three largest small businesses in the state
  • or the health benefit plan from the largest Health Maintenance Organization in the state.

In making its EHB decision, each of the 50 states will have to face conflict between its own financial interests—and the public health interest of its citizens, and the financial interests of its own business community. Here’s why:

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I am currently using Mental health sevices. With these benifits I am able to give back to the community and function on a higher level. With out this I would be unable to participate in any thing and would end up needing a lot more services which would cost my state more money in the end then if I was still able to function and work.

Dr. Manderscheid - I appreciate your leadership on this important issue and have submitted the following comment to HHS:

For years, the CDC and NIH/NIMH have presented data that shows how much untreated behavioral health problems and substance abuse cost individuals and employers in terms of lost lives, lost incomes, absenteeism and lower productivity. Our nation cannot afford to not provide for accessible behavioral health care and substance abuse treatment in the implementation of the Affordable Care Act. Failing to provide truly accessible behavioral care and substance abuse treatment would be horribly short-sighted and, over time, more costly.

Angela M. Oddone LMSW (NYS), LCSW (VA)

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Ron Manderscheid

Exec. Dir., NACBHDD and NARMH

Ron Manderscheid

@DrRonM

www.nacbhdd.org

Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County...