CQC warns that scaling back Essential Health Benefits would shift costs onto patients already facing rising premiums and medical debt

Washington, D.C. —Consumers for Quality Care (CQC) submitted formal comments to the Centers for Medicare and Medicaid Services (CMS) in response to the Agency’s Request for Information (RFI) regarding the Essential Health Benefits (EHBs) Framework. In the comments submitted yesterday, CQC urges CMS to preserve and strengthen these critical consumer protections rather than give insurers greater flexibility to reduce covered benefits. 

The RFI comes as Americans nationwide face rising health care costs, growing medical debt, and increasing barriers to care, even among plans designed to be affordable. Rising deductibles and out-of-pocket costs, combined with insurer practices like prior authorization, step therapy, narrow networks, and copay accumulator programs, already leave patients vulnerable to delayed and unaffordable care. CQC warned that these burdens fall hardest on people with chronic illnesses, seniors, individuals with disabilities, and low-income families, many of whom rely on Marketplace plans for coverage.

Section 1302(b) of the Affordable Care Act (ACA) requires that all individual and small-group health plans cover ten categories of Essential Health Benefits, including ambulatory care, hospitalization, maternity and newborn care, mental health and substance use disorder services, and prescription drugs. Before this requirement took effect, almost 10% of Americans lacked prescription drug coverage, more than 60% lacked maternity coverage, and nearly 20% lacked any coverage for mental health care. Consumers often discovered these gaps only after they became sick or injured.

“Essential Health Benefits are a vital part of the Affordable Care Act, guaranteeing that every American enrolled in an individual or small-group plan has access to the care they actually need,” said Jim Manley, CQC Board Member and former senior advisor to Senators Edward Kennedy and Harry Reid. “Weakening this framework wouldn’t lower health care costs, but rather shift those costs onto patients through higher out-of-pocket spending, delayed treatment, and worse outcomes.”