Kaine and Baldwin Lead Senators in Calling on Biden Administration to Strengthen Essential Health Benefits

WASHINGTON, D.C. – U.S. Senators Tim Kaine (D-VA) and Tammy Baldwin (D-WI), both members of the Senate Health, Education, Labor and Pensions (HELP) Committee, led their colleagues in sending a letter to Department of Health and Human Services (HHS) Secretary Xavier Becerra and Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure regarding persistent coverage gaps in Essential Health Benefits (EHB). In the letter, the senators called on the HHS to initiate rulemaking to institute a minimum standard of coverage for EHBs and to establish a permanent structure to review and update EHBs, closing dangerous coverage gaps and improving health care access for communities across the country.  

“The lack of detailed federal guidelines and a regular process to review EHBs has resulted in patchwork coverage across states and left too many people without access to comprehensive health insurance…Unfortunately, many states are allowing for inadequate coverage across EHB categories,” wrote the senators. “…This patchworked approach contributes to the medical debt crisis our country is facing; millions of insured individuals have medical bills for services not covered by their insurance and they simply cannot afford to pay them.”

Included as part of passage of the Affordable Care Act, EHBs are a set of ten required services, like maternity and newborn care, mental health and substance use disorder services, and prescription drug coverage, that must be covered by Marketplace and some commercial insurance plans. However, the administration has not used its statutory authority to set a minimum standard of coverage under these categories or set a regular process for reviewing and updating coverage. With more than 20 million Americans enrolled in Marketplace coverage it is critical to set minimum standards to avoid gaps in coverage.

Virginia, like many states, has been impacted by these gaps. Inadequate coverage means Virginians do not have access to the services they need – even with insurance. For example, basic but necessary care like preventive dental coverage and routine eye exams for adults, as well as coverage of medications to treat substance use disorder like methadone or buprenorphine – which are critical to recovery. When Virginians do not have access to these basic services, they must pay out-of-pocket or go without care. This lack of access can result in mounting medical debt.

“I lost one of my back molars because I couldn't get dental insurance from McDonald's because they switched hands midstream and made it into 2 separate jobs I each worked 1 year at instead of 2 years at one job so I could be eligible for benefits. I don't want anyone else to lose a tooth needlessly,” said Kimberly of Courtland, Virginia. “I suffered so much pain and had to get a special credit card cosigned by my parents just to get it out and end the pain and we'd have still owed money on it if it hadn't gotten grandfathered into their bankruptcy.”

“I had a few benign growths that were constantly chafing against my clothing and my Dr was concerned they’d become infected so she removed them. My insurance denied the visit and I now owe over $300 for a 30 second procedure,” shared Alison of Newport News, Virginia.

“I'm in the top income quartile for my city. I have all the best buy-up insurance plans my employer offers. Last year, I had to spend nearly 10% of my annual take home pay to have a single tooth fixed AFTER dental insurance,” explained Justin of Richmond, Virginia. “I have multiple other infected teeth but that was the worst and the only one I could afford to handle. Tooth infections can lead to death. They should be covered under health insurance.”

“Thirteen years after ACA passage, we are asking the administration to act in the spirit of the law and update the ACA's standards to fill in crucial gaps and make health insurance coverage more comprehensive. Now more than ever, it's time for HHS to act, as there are major inequities in the services covered, leaving far too many people underinsured resulting in high out-of-pocket costs and medical debt, or people foregoing important, needed care,” said Emily Stewart, executive director of Community Catalyst, a national health justice organization that has convened more than 50 local, state and national organizations urging the Biden administration to act. “With rising health care costs, and 4 in 10 adults with medical debt, it’s critical that policymakers continue to address the gaps and inconsistencies that exist – including for mental health, maternity and dental care. This is a simple yet important and long overdue action the Biden administration can take to improve coverage for millions of people across the country. We applaud the lawmakers urging action.”

To protect millions of individuals from suffering from lack of care, medical uncertainty, and debt, Kaine is urging HHS to institute a minimum standard of coverage for every EHB category, to establish a permanent structure to regularly review and update EHBs, and to expand the scope of services within the current EHB categories. Implementing and expanding standards will lead to increased access to care, better health outcomes, and improve the wellbeing of communities – especially vulnerable populations – throughout the nation.

Improving access to health care and lowering health care costs are among Kaine’s top priorities on the HELP Committee. Kaine has previously introduced the Help Ensure Lower Patient (HELP) Copays Act, legislation that would protect patients from harmful insurance and Pharmacy Benefit Manager (PBM) practices by closing a loophole that allows insurance to not cover some drugs that people with chronic diseases need to survive. This bill would close an EHB loophole to ensure that any service covered by a health plan is considered part of their EHB package and therefore cost sharing for that services counts towards annual out-of-pocket limits. He has also introduced bipartisan legislation to lower drug costs and level the playing field for patients by prohibiting PBMs from making more money on high-cost drugs than they do from lower-cost drugs. Kaine also voted for the Inflation Reduction Act, which passed in the Senate by one vote, to cap the cost of insulin to $35 per month for most patients and lower health care costs for thousands of Virginians. 

In addition to Kaine and Baldwin, the letter was signed by U.S. Senators Ed Markey (D-MA), Tina Smith (D-MN) and Ben Ray Luján (D-NM).

The full text of the letter can be found here and below.

Dear Secretary Becerra and Administrator Brooks-LaSure:

We are writing to thank the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) for their ongoing efforts to make health coverage more comprehensive, affordable, and accessible for everyone. The recently proposed Notice of Benefit and Payment Parameters (NBPP) for 2025 takes an important step forward in addressing coverage gaps in Essential Health Benefits (EHB). We applaud the greater flexibility this rule would grant states in crafting their own EHB coverage standards. However, even with these improvements, stronger federal standards are imperative to achieve the purpose of the EHBs: ensuring that health insurance works for people, regardless of where they live. Therefore, we strongly urge HHS to initiate rulemaking to update and revise the EHBs.

When Congress established the EHBs nearly 14 years ago, it directed the Secretary of HHS to define EHB coverage and instructed HHS to regularly review and update the EHBs. However, HHS ultimately delegated many decisions about specific covered services to the states and insurance carriers. While the intent may have been to provide flexibility in addressing regional health needs, the lack of detailed federal guidelines and a regular process to review EHBs has resulted in patchwork coverage across states and left too many people without access to comprehensive health insurance coverage.

Comments submitted in response to the December 2022 CMS Request for Information on Essential Health Benefits highlighted that coverage varies greatly by state. Unfortunately, many states are allowing for inadequate coverage across EHB categories. For example, the current EHB framework does not clearly define pediatric services beyond preventive services and oral and vision care. As a result, there have been notable exclusions for children, particularly those with special needs and disabilities. Similarly, while the EHBs require coverage of mental health and Substance Use Disorder (SUD) services, the standards are so broad that access to life-saving SUD treatment services and medications, like buprenorphine, methadone, and naltrexone, varies widely based on where a patient lives and what plan they choose. Furthermore, the lack of clarity around EHB coverage for maternal care has resulted in limits on prenatal and delivery services coverage and inconsistent coverage of evidence-based pre- and post-partum services and supports. This patchworked approach contributes to the medical debt crisis our country is facing; millions of insured individuals have medical bills for services not covered by their insurance and simply cannot afford to pay them.

Fortunately, HHS has the authority to address these oversights and provide relief to millions of people. Sections 1302(b)(4)(G) and 1302(b)(4)(H) of the Affordable Care Act specifically direct the Secretary of HHS to periodically review and update the EHB. Under this authority, the Secretary must consider barriers people are facing in accessing the services they need, changes in medical or scientific advancement, and gaps in EHB coverage. Given the Secretary’s clear regulatory authority and the persistent gaps in coverage identified above, HHS should take immediate action to:

• Institute a minimum standard of coverage that applies to every EHB category, with sufficient detail to ensure a nationwide floor for coverage by most health plans;
• Establish a permanent structure for regularly reviewing and updating EHBs that is transparent, equitable, and prioritizes meaningful opportunities for stakeholder engagement; and
• Expand the scope of services within the current EHB categories, where appropriate, through the review process.

Too many individuals forego medically necessary care because they cannot afford treatment or risk going into medical debt. HHS has the power to mitigate this burden through updating the EHBs. We urge you to initiate a new rule and help ensure that over 40 million people will have comprehensive health insurance coverage for the services they need.

Sincerely,

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