Health Care Reform and Essential Benefits

The Affordable Care Act (ACA) offers hope to millions of Americans who will gain insurance coverage under it; and the definition of essential benefits plays a crucial role in turning that hope into a useful reality. As Secretary Sebelius of the Department of Health and Human Services (HHS) said recently:

The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures plans offered in the new Health Insurance Exchanges, and in the individual and small group markets, offer a package of essential health benefits that are equal in scope to what employers typically offer today. (1)

HHS, with the assistance of the Institutes of Medicine (IOM) and the Department of Labor is currently engaged in the process of defining essential benefits. The ACA mandates that the essential healthcare benefits packages have an appropriate balance among categories of care and account for the health care needs of diverse segments of the population. Moreover, in addition to the general prohibitions against discrimination already in the law,the ACA calls for an absence of discrimination in the definition of the essential benefits package based on age, disability, or expected length of life. (2)

A definition of essential benefits that affords no real protections against the alternative threats of suffering from disease and financial destruction wastes an important opportunity to improve the lives of Americans. To provide meaningful and effective health care, the insurance benefits must provide access to medicines at reasonable and predictable costs. Coverage with unaffordable out of pocket expenses is not coverage—not in any meaningful sense. The costs to patients associated with obtaining treatments, or accessing prevention and wellness services to protect their health, under these plans must be predictable and affordable to fulfill their promise.

Treatments cannot work for patients if patients do not follow them. Some estimates have found that less than one-third of AIDS patients, for example, are able to follow their course of treatment. (3) There may be several reasons for a patient finding it difficult to stay on a course of treatment, but their insurance formulary should not be one of them. A 2001 Harris Interactive poll found that one in five US adults missed doses of a prescription they needed because of high costs, and low income adults were twice as likely to miss a dose or not fill a prescription as the general public.(4)

Consistent with its purpose, the ACA should help to ensure access to quality health care for all. The essential benefits package is not just a requirement of the qualified plans that will be sold in the state exchanges; it is a statement we as Americans make about ourselves and the kind of people we are. Our investments in science and technology have given us a rich array of treatments that can be used by physicians to prescribe the best course of treatment for each individual. Each person should have the treatment that works best for them and their own genetic makeup; one size does not always fit all.

High copayments and coinsurance increase patients’ out-of-pocket costs and can force some to go without lifesaving prescriptions. This contradicts the basic idea of insurance protection and the goals of the Affordable Care Act. The ACA should be an important step toward achieving health care equality in America. The definition of essential benefits is key to making sure all patients, regardless of their income level, are able to afford quality health care.



(3) Paterson D t al. “Adherence to Protease Inhibitor Therapy and Outcomes in Patients with HIV Infection”. Annals of Internal Medicine. 2000. 133, 1: 21-30.

(4) Harris Interactive. Out-of-pocket costs may be a substantial barrier to prescription drug compliance. Health Care News. 2001:1(32).


Karen Boykin-Towns is a member of the NAACP’s National Board of Directors, Chairman of the National Board Health Committee, and President of the NAACP’s Brooklyn, New York Branch.

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