As part of their plan to replace the ACA with reform that would lower premiums, Congressional Republicans have proposed alleviating the requirement that health insurers provide essential health benefits. However, a new analysis from the Urban Institute and the Robert Wood Johnson Foundation finds EHBs account for just a small percentage of overall monthly premiums, on average.
Essential health benefits, a set of 10 categories of services the ACA requires all health plans to cover, include ambulatory services, emergency services, maternity care, hospitalization, prescription drugs, laboratory services and rehabilitative services, among others.
The report finds that maternity and newborn care account for 6 percent of premium dollars, while habilitative and rehabilitative care account for 2 percent. Pediatric dental and vision care account for 1 percent.
On the other hand, the largest shares of premium dollars under ACA plans are attributable to the costs of office-based care (30 percent), prescription drugs (22 percent), outpatient facility care (17 percent) and inpatient care (15 percent), which are generally regarded as fundamental aspects of care.
Although eliminating specific benefits from coverage can lower premiums, it increases the cost of that type of care for those who need it. The study found the per-person costs of insuring EHBs are relatively low, and account for a small percentage of the overall premium when costs are spread across a large population that includes a range of ages and healthcare risks. Furthermore, experts say placing the costs of care fully on users can make necessary services unaffordable to them. For example, maternity/newborn care would cost an additional $13,888 if only those who needed it had to pay, according to the report.