The United States health care system is a complex landscape, constantly evolving to meet the diverse needs of its population. At the heart of recent reforms lies the Affordable Care Act (ACA), which introduced significant changes to health insurance coverage. A critical component of the ACA is the mandate for Essential Health Benefits (EHB), ensuring that certain health services are covered in individual and small group markets. Understanding what these benefits are, how they are defined, and what changes might be needed in the United States health care program is crucial for patients, providers, and policymakers alike.
This article delves into the framework of Essential Health Benefits, examining how they are established and updated. We will explore the flexibility afforded to states in defining their EHB benchmark plans and discuss the ongoing policy adjustments that shape the landscape of healthcare coverage in the US. By understanding the current system, we can better identify what changes are needed in the United States health care program to improve access, affordability, and quality of care for all Americans.
Essential Health Benefits (EHB) Under the ACA: A Foundation of Coverage
The Affordable Care Act (ACA) brought about a fundamental shift in health insurance by requiring most plans to cover a set of “essential health benefits.” These EHBs are not arbitrary; they are categorized into ten key areas that represent core healthcare services. These categories are designed to ensure comprehensive coverage and include:
- Ambulatory patient services: Care received without being admitted to a hospital, such as doctor’s office visits and outpatient procedures.
- Emergency services: Treatment for sudden and serious illnesses or injuries, including emergency room visits.
- Hospitalization: Inpatient care, including surgery and overnight stays in a hospital.
- Maternity and newborn care: Services for pregnant women and new mothers, as well as care for newborns.
- Mental health and substance use disorder services: Crucially includes behavioral health treatment, addressing both mental health and addiction.
- Prescription drugs: Coverage for medications prescribed by a doctor.
- Rehabilitative and habilitative services and devices: Services and devices to help individuals recover or maintain physical, mental, or cognitive abilities.
- Laboratory services: Tests and screenings performed in a lab, aiding in diagnosis and treatment.
- Preventive and wellness services and chronic disease management: Includes vaccinations, screenings, and programs to manage chronic conditions and promote overall health.
- Pediatric services: Comprehensive care for children, including dental and vision care.
These ten categories form the bedrock of essential health benefits, aiming to provide a minimum standard of coverage across health insurance plans. However, the specifics of these benefits are further defined at the state level, adding a layer of complexity to the system.
State Benchmark Plans: Tailoring EHB to Local Needs
While the ACA outlines the ten categories of EHB, the law allows for state-specific customization through EHB-benchmark plans. These benchmark plans are the foundation upon which states define the exact scope of essential health benefits within their borders. The Department of Health and Human Services (HHS) regulations guide this process, allowing states to select benchmark plans that were sold in 2012 for the initial years (2014-2016) and plans from 2014 for subsequent years (2017-2019).
For plan year 2020 and onwards, states gained increased flexibility in choosing their EHB-benchmark plans. This flexibility acknowledges that healthcare needs and priorities can vary across states. The Centers for Medicare & Medicaid Services (CMS) has provided states with options to update their benchmark plans, recognizing the need for the program to adapt over time.
This flexibility included several options for states up to plan year 2025:
- Option 1: Adopt the EHB-benchmark plan of another state from 2017.
- Option 2: Replace specific categories of their existing 2017 benchmark plan with those from another state’s 2017 plan.
- Option 3: Design a completely new set of benefits to serve as their benchmark plan.
For plan years 2026 and beyond, CMS consolidated these options, streamlining the process to allow states to select a new set of benefits as their EHB-benchmark plan (effectively option 3). This evolution reflects a move towards simplifying the process while still allowing for state-level tailoring.
States choosing to update their EHB-benchmark plans must adhere to documentation requirements, ensuring transparency and accountability. These requirements include submitting confirmation templates, actuarial reports, plan documents, summary charts, and potentially formulary drug lists.
Ongoing Updates and Policy Changes: Adapting to Evolving Needs
The Essential Health Benefits framework is not static. Recognizing the dynamic nature of healthcare and medical advancements, HHS and CMS regularly issue notices and updates to refine EHB policies. The annual HHS Notice of Benefits and Payment Parameters is a key mechanism for these updates.
Recent notices, such as the Final 2025 HHS Notice, have focused on several key areas:
- EHB-Benchmark Plan Update Process Improvements: Streamlining and clarifying the process for states to update their benchmark plans, reducing administrative burden.
- Routine Adult Dental Services: Expanding the scope of essential benefits to include routine dental care for adults starting in 2027, a significant expansion addressing a previously excluded area.
- Prescription Drug Benefits: Adjustments to ensure adequate coverage of prescription drugs, reflecting the ever-increasing importance and cost of medications.
- State-Mandated Benefits and Defrayal: Clarifying how state-mandated benefits interact with EHB requirements and financial responsibilities.
These updates demonstrate a commitment to ensuring that EHB remains relevant and responsive to the evolving healthcare landscape. However, despite these advancements, there are still areas within the US healthcare program where changes may be needed to further strengthen the system and improve patient outcomes.
Areas for Potential Changes in the United States Health Care Program
While the ACA and EHB have made significant strides in expanding healthcare coverage, challenges and areas for improvement remain. When considering what changes are needed in the United States health care program, several key themes emerge:
- Affordability: Despite expanded coverage, healthcare costs remain a major burden for many Americans. Further changes are needed to control costs for premiums, deductibles, and out-of-pocket expenses. This could involve strategies like negotiating drug prices, promoting value-based care, and strengthening cost-sharing reduction programs.
- Coverage Gaps: While EHB ensures a baseline of coverage, gaps still exist. For example, while routine pediatric dental and vision are included, adult dental and vision coverage has been more limited until recent updates. Addressing these remaining gaps and ensuring truly comprehensive coverage is crucial.
- Mental Health Parity Enforcement: While mental health and substance use disorder services are included in EHB, ensuring true parity with physical health coverage remains a challenge. Stronger enforcement of mental health parity laws is needed to guarantee equal access to care.
- Prescription Drug Costs and Access: The high cost of prescription drugs is a persistent problem. Changes are needed to improve drug pricing transparency, negotiate lower prices, and ensure access to essential medications without financial hardship.
- Administrative Complexity: The US healthcare system is notoriously complex, leading to administrative burdens for patients and providers alike. Simplifying insurance processes, reducing paperwork, and improving system navigation could significantly enhance the patient experience.
- Health Equity: Disparities in healthcare access and outcomes persist across different racial, ethnic, and socioeconomic groups. Targeted interventions and policy changes are needed to address these inequities and promote health equity for all Americans.
- Focus on Preventative Care: While preventive services are included in EHB, shifting the healthcare system towards a greater emphasis on prevention could improve long-term health outcomes and reduce overall costs. This includes promoting wellness programs, expanding access to preventative screenings, and investing in public health initiatives.
Addressing these areas will require ongoing dialogue, policy innovation, and a commitment to building a healthcare system that truly serves the needs of all individuals in the United States. The Essential Health Benefits framework provides a solid foundation, but continuous improvement and adaptation are essential to realizing the full potential of the ACA and ensuring a healthier future for the nation.
Conclusion: A Dynamic System in Need of Continuous Improvement
The Essential Health Benefits (EHB) are a cornerstone of the Affordable Care Act, establishing a minimum standard of coverage and aiming to improve access to essential healthcare services for millions of Americans. The flexibility afforded to states in defining their EHB-benchmark plans recognizes the diverse needs across the country, while ongoing policy updates reflect a commitment to adapting to the evolving healthcare landscape.
However, the journey towards a truly accessible, affordable, and high-quality healthcare system in the United States is ongoing. As we have explored, there are still crucial areas where changes are needed in the United States health care program. From tackling affordability and coverage gaps to strengthening mental health parity and addressing health inequities, the challenges are significant but not insurmountable. By continuing to examine, adapt, and improve upon the existing framework, we can strive towards a healthcare system that better serves the needs of all Americans, ensuring healthier lives and a more equitable future.
