As we approach the eve of Affordable Care Act (ACA) implementation, it is exceptionally important for us to take stock, assess where we actually stand, and then act. Three core ACA features deserve specific action—the Essential Health Benefit (EHB), the State Medicaid Expansion, and the State Marketplace. These mechanisms will determine how many persons will become newly enrolled in health insurance, and what insurance benefits will actually be available to them.
The ACA is expected to provide new insurance coverage for about 32 million persons; half will be covered through the Medicaid Expansion, and half will be covered through the State Marketplaces. We estimate that as many as 11 million of these persons will have a behavioral health condition at the time of enrollment, and that the majority of these persons will have a primary substance use condition (see http://www.acmha.org/content/events/national/WHC_Universal_Coverage.pdf).
The Essential Health Benefit
The EHB must cover 10 specific types of benefits including mental illness and substance use disorder services. For both of these services, the benefit must be at parity with that for the medical/surgical benefit. This means that the specific insurance benefits for each of these conditions cannot be more restrictive than those for the medical/surgical benefit. The EHB also is exceptionally important because it will determine the amount of federal funds a state will receive for its optional Medicaid Expansion, as well as the size of the federal tax subsidy available to those insured under the State Marketplace.
In 2012, each state was given the opportunity to define its EHB from a benchmark health insurance plan. It could choose from among 10 options defined by the U.S. Secretary of Health and Human Services. These 10 options included the three largest federal employee health benefit plans, the three largest state employee health benefit plans, the three largest small group plans in the state, and the largest health maintenance organization in the state. If a state elected not to choose any plan, then the largest small group plan in that state became its default plan.
A total of 19 states and the District of Columbia have chosen a small group plan for their EHB; 3, a state employee plan; and 4, an HMO plan. The remaining 24 states have defaulted to a small group plan. You can learn about the specific situation in your state at: http://www.kff.org/healthreform/quicktake_essential_health_benefits.cfm, and you can find more detailed information at: http://www.ncsl.org/issues-research/health/state-ins-mandates-and-aca-essential-benefits.aspx#Appendix%203. As a key point of comparison, you can access the model Coalition for Whole Health benefit at http://www.coalitionforwholehealth.org/2012/01/ehb-consensus-principles-and-service-recommendations/.