A recent announcement by Vice President Pence added to the confusion surrounding the administration’s response to the coronavirus epidemic. Pence stated that the Department of Health and Human Services (HHS) “has already denominated a test for the coronavirus to be an essential health benefit, which ensures that it will be covered by people’s private health insurance.” Pence’s claim is misleading; coverage for the widespread coronavirus testing is far from guaranteed. Moreover, this apparent embrace of the Affordable Care Act (ACA) comes at the same time the administration is asking the Supreme Court to completely nullify the law, and after three years of steadfastly trying to sabotage ACA protections.
The ACA “Essential Health Benefits” (EHB) requirement applies to most individual and small group plans, including plans sold through the ACA marketplaces. EHBs include primary care, hospitalization, prescription drugs, preventive care, and laboratory services. Prior to the ACA, federal law did not require minimum coverage standards for health plans. As a result, consumers often did not have health coverage for services now covered as EHBs. The EHB requirement closed health care coverage gaps that for years had left individuals underinsured. While states have different requirements regarding coverage of EHBs, it is likely that coronavirus testing will be covered as part of the EHB laboratory services category.
However, the Trump administration has been working to expand the availability of health care plans that are exempt from EHB coverage requirements – short-term plans, also called junk plans. A recent study found that consumers who purchase these plans are left with significant coverage gaps for key services and high out of pocket costs. The proliferation of junk plans will leave many people who are seeking coronavirus testing and treatment without adequate coverage and surprise medical bills.
Moreover, the Centers for Medicare & Medicaid Services (CMS) issued clarifying guidance that Medicare should cover coronavirus testing. However, the new laboratory billing codes and procedures do not go in to effect until April. In Medicaid, where laboratory services are a mandated benefit, enrollees should be able to access coronavirus testing and necessary services including prescription drugs and hospitalization. Yet again, under the Trump administration’s recent efforts to cap federal Medicaid spending available to states through Medicaid block grants, access to covered services would be severely limited.
Another potential obstacle impeding access to necessary care is cost sharing in the form of deductibles, copays, and coinsurance, which deters people, especially those with low incomes, from accessing needed care. Despite the Vice President’s assertion that private insurance would cover coronavirus testing without cost-sharing, the ACA’s prohibition on cost-sharing only applies to preventive services that have been recommended by the U.S. Preventive Services Task Force (USPSTF). Nonetheless, states and the federal government can take action to guarantee affordability of the test. Several state insurance commissioners, including California, Maryland, Washington, Wisconsin, have ordered insurers under their authority to waive deductibles and copays for coronavirus testing, and some insurers have voluntarily agreed to suspend cost sharing for testing.
Similarly, members of Congress recently called upon HHS to take necessary steps to ensure that coronavirus tests and treatment are accessible and affordable by persons in private plans, to eliminate cost sharing for Medicare and Medicaid enrollees, and allow access to testing and treatment for persons without insurance. However, in a prime time address to the nation, the President announced no such action. In fact, the administration’s most significant health care accomplishment has been the rise in the number of people without health insurance – up by more than two million, including 400,000 newly uninsured children, and the first such increase since Congress passed the ACA ten years ago. That legacy may soon be eclipsed by a coronavirus pandemic with mortality rates projected between .1 – 3.4 percent.
A growing number of Americans, are coming to realize what health care advocates have long understood – that the ACA, with its essential health benefits and coverage standards in private health plans, expanded access to Medicaid, and other protections, has been a life-saver for millions of people and is a vital tool to combat disease outbreaks and other public health emergencies. Hopefully, the Trump administration will soon realize that too.