American College of Obstetricians & Gynecologists Issues Public Comment on Employee Benefits Security Administration Proposed Rule
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The
Proposals in the NPRM
Grandfathered group health plans are those that had enrollees prior to passage of the Patient Protection and Affordable Care Act (ACA) and that have not cut benefits or increased costs to enrollees. Grandfathered group health plans are not required to offer the same amount of patient protections as Marketplace group health plans, including, but not limited to, certain benefit and cost-sharing requirements. According to the
Approximately 13 percent of covered workers were enrolled in grandfathered group health plans in 2019 (down from 16 percent in 2018)./2/,/3
This translates to roughly 17.5 million individuals. Given that grandfathered group health plans continue to be offered by one-fifth of all
Under current regulation, there are six changes that would cause a grandfathered group health plan to lose its grandfathered status. These include: 1) elimination of all or substantially all benefits to treat a particular condition; 2) any increase in a percentage cost-sharing requirement; 3) an increase in a non-copay fixed-amount cost-sharing requirement (such as a deductible or out-of-pocket maximum) that exceeds certain thresholds; 4) an increase in a copay that exceeds certain thresholds; 5) a decrease in the employer's contribution rate by more than five percentage points; or 6) the addition of new annual dollar limits on benefits./4
The NPRM proposes to allow grandfathered plans to adjust patient cost-sharing requirements without risk of losing their grandfathered status.
Impact on Patient Access to Care and Health Outcomes
Research demonstrates that requiring financial contributions from patients for health care services has adverse effects on access to and utilization of care./5
This includes utilization of both highly effective and less effective services in equal proportions./6
For example, one study aiming to describe the relationship between the elimination of out-of-pocket costs and women's use of preventive care found that women with high out-of-pocket costs had lower utilization rates compared to their peers with lower cost-sharing obligations./7
Another study found that copayments and other forms of cost-sharing were associated with significantly lower mammography rates among women who should have undergone mammography screening according to accepted clinical guidelines./8
Premiums and other forms of patient financial contributions also serve as a barrier to receiving and maintaining coverage over the long term./9
These effects are further compounded for women, who on average earn lower wages, have fewer financial assets, accumulate less wealth, and have higher rates of poverty than men./10,/11
Women are also more likely than men to report forgoing needed health care due to cost (26 percent of women vs. 19 percent of men)./12
ACOG is concerned that, under the proposals in this NPRM, women enrolled in grandfathered group health plans may face larger out-of-pocket costs for certain services. As a result, some women may be unable to receive medically necessary care due to an inability to pay.
One essential women's health service where costs are likely to be prohibitive under the flexibilities of this NPRM is maternity care. Childbirth is the leading cause of hospitalization in
Under the NPRM, any increase in patient cost-sharing for this critical health care service would be detrimental to maternal and infant health.
Increased patient cost-sharing is especially concerning given our nation's ongoing maternal mortality crisis. As the Departments are well aware,
The stark racial and ethnic inequities in maternal mortality are also significant and concerning: Black women are three to four times and American Indian/
Access to and utilization of prenatal care are important contributors to maternal health outcomes.
Delaying prenatal care due to cost could lead to delayed diagnosis of certain pregnancy-related conditions, putting patient health at risk and driving up costs later in pregnancy. Delaying care related to labor and delivery could force some women to go to an emergency department (ED) for childbirth, multiplying costs to the patient and to the health system. Delaying or avoiding appropriate postpartum follow up is equally risky. National and state data indicate that a growing number of preventable maternal deaths are occurring in the postpartum period, well after hospital discharge./17
It is paramount that women be able to receive care in the critical postpartum period.
Maternal health is an important priority for HHS and the
At a time when the Administration is focused on improving maternal outcomes, grandfathered health plans should not be permitted to make changes that could prove a detriment to health care access and maternal health outcomes.
Special Considerations Given the COVID-19 Pandemic
In addition to the concerns detailed above, ACOG believes it is ill-advised that the proposals in this NPRM be advanced amid the COVID-19 public health emergency and attendant economic downturn.
Current projections from the
This is not an appropriate time to place greater financial burden for health care spending on patients.
ACOG recommends that the NPRM on
Thank you for the opportunity to provide comments on the Departments' NPRM on
Sincerely,
Senior Director, Health Economics & Practice Management
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Footnotes:
1/
2/ Ibid.
3/ Ibid.
4/ Final Rules for Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections Under the Affordable Care Act. 80 Fed. Reg. 72194 (
5/ National Health Law Program. Medicaid premiums and cost sharing.
6/ Brook RH, Keeler EB, Lohr KN, Newhouse JP, Ware JE, Rogers WH, Davies AR, Sherbourne CD, Goldberg GA,
7/ Dalton VK, Carlos RC, Kolenic GE, Moniz MH, Tilea A, Kobernik EK, Fendrick AM. The Impact of Cost Sharing on Women's Use of Annual Examinations and Effective Contraception. AJOG 2018;219(1).
8/ Trivedi AN, Rakowski W, Ayanian JZ. Effect of Cost Sharing on Screening Mammography in Medicare Health Plans. NEJM 2008;358(4):375-383.
9/
10/
11/
12/ Ibid.
13/ Moniz MH, Fendrick AM, Kolenic GE, Tilea A, Admon LK, Dalton VK. Out-Of-Pocket Spending For Maternity Care Among Women With
14/
15/ 'The US has the highest maternal mortality rate in the developed world. Why?'
16/
17/ In 2018, a total of 658 women were identified as having died of maternal causes in
18/
19/
20/
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The proposed rule can be viewed at: https://beta.regulations.gov/document/EBSA-2020-0006-0001
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American Hospital Association Issues Public Comment on Employee Benefits Security Administration Proposed Rule
Center on Budget & Policy Priorities Issues Public Comment on Employee Benefits Security Administration Proposed Rule
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