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What’s at Stake if Essential Health Benefits are Scrapped? Pediatric Benefits, Protection from Lifetime Limits

As House leaders scramble to get enough votes to send the American Health Care Act to the Senate, there is a lot of horse-trading going on. None of it to the benefit of kids enrolled in Medicaid or private insurance. The most recent Affordable Care Act provision on the chopping block is the Essential Health Benefits package.

As my colleague, Joan Alker wrote, the new Medicaid block grant option would allow states to gut benefits for kids – even those critical development screening and treatment services that help nip problems in the bud before they turn into learning disabilities or other struggles in school. Now it appears that House leaders are willing to do that with private insurance by eliminating the requirement that plans cover the 10 basic categories of coverage, known as Essential Health Benefits (EHB). Notably, one of the ten categories is “pediatric services”, but what’s at risk is broader than that.

So what’s at stake?

Preventive Care – The EHB standard for preventive health care for kids is based on the American Academy of Pediatricians’ Bright Futures. Bright Futures establishes guidelines for screenings at set intervals to check for healthy development and to detect early and treatable issues with hearing, vision, and social and emotional development. If preventive care is no longer required, plans won’t even have to cover basic well-child checkups or immunizations.

Vision and Oral Health Care – Vision and oral health care are specifically included in pediatric services under the EHB. These services are not typically part of private insurance packages. But they are essential to children’s health and success in school.

Habilitative Services – The ACA established specific requirements for states to ensure that plans covered habilitative services for kids. These services are essential for kids with special health care needs who may need extra services such as physical, occupational or speech therapy to help them achieve their full potential.
But there’s more. It’s not just the types of services included in the EHB that are at stake.

Lifetime and Annual Maximum Limits – Prior to the ACA, insurers could set limits on the total amount of benefits that a plan would cover in a person’s lifetime. This was often set at $1 million, a cap that can easily be exceeded by a child who has cancer or needs a life-saving transplant. Children with disabilities who need extensive services are also at risk for exceeding a lifetime or annual maximum. But because these caps are only associated with EHB, they too would be cut.

Out-of-Pocket Caps – The ACA also sets limits on the amount of cost-sharing that can be passed on to an individual or family. Without these protections, low-income families will struggle with medical debt that puts their children’s health and family’s economic security at risk.

In less than a week, the AHCA has gone from bad to worse. What emerges from behind closed-door negotiations is likely to be even more devastating to children’s health and well-being. Government is supposed to protect the vulnerable and disadvantaged in society. To paraphrase Hubert Humphrey: “It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the disabled.” The AHCA doesn’t pass that moral test.

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