It’s been thirteen years since the Affordable Care Act (ACA) passed. While there is still work to be done to expand and preserve coverage, great strides have been made since the ACA’s passage in reducing health care uninsurance rates. However, the nation’s health care system in many ways remains inequitable and, for many people, health care that truly meets people’s needs is still unaffordable, even with insurance. There are many reasons these challenges persist, such as insurance plans paying less than expected for care, not covering needed medications, having prohibitively high out of pocket costs, and requiring prior approval for services.
An effort moving forward in Congress—the Telehealth Benefit Expansion for Workers Act of 2023—purports to improve access to affordable care by allowing employers to offer telehealth-only plans as a benefit to their employees. Telehealth—the provision of medical care through means other than in-person visits, such as through phone calls, texts, a website, or apps—saw a surge in use during the pandemic, for good reason. But the type of telehealth plans proposed in this bill won’t solve any of the major problems with health insurance coverage today and instead could risk further undermining access to robust coverage and services. While telehealth certainly should be part of affordable, equitable, comprehensive coverage, allowing employers to offer stand-alone telehealth-only plans could actually make it harder for people to get the care and coverage they need, especially people who have been most marginalized by inequity.
The ACA attempted to address uninsurance and underinsurance, but encouraging additional excepted benefits undermines this goal
When the ACA passed in 2010, one of the primary goals was to address the major problem of uninsurance and underinsurance in the United States. The ACA, as well as follow-up legislation under the American Rescue Plan Act (ARPA), expanded coverage by building on the country’s fragmented system of private and public insurance, most notably by creating new insurance marketplaces to offer coverage to people who could not get it through their employer and were not eligible for Medicare or Medicaid. People with incomes between 100 percent and 400 percent of the federal poverty level (FPL) qualify for subsidized comprehensive coverage in the marketplace if their employers do not offer comprehensive insurance.
To address underinsurance—that is, skimpy health care plans that offer minimal coverage, a common problem at the time—the ACA ushered in multiple consumer protections, such as annual and lifetime limits on out-of-pocket costs, guaranteed coverage of essential health benefits, and eliminating pre-existing condition exclusions. However, the law did allow for “excepted benefits”—benefits that are not considered as essential to provide primary health coverage, such as dental or vision plans, and indemnity health coverage. While employers are permitted to offer excepted benefits pre-tax to their employees as a form of health care coverage, they cannot fulfill their employer responsibilities under the ACA by offering only these benefits. Additionally, before the individual mandate was functionally repealed in 2017, these benefits would not count toward meeting this individual requirement to have insurance coverage.
The House bill under consideration would make stand-alone telehealth plans an excepted benefit. Just as we have seen with other excepted benefits, we know that allowing employers to offer this type of standalone plan next to other, more comprehensive coverage options would undermine the ACA’s efforts to ensure that people have comprehensive coverage. There are a few reasons why. First, there is a risk that employees could mistakenly sign up for it assuming that it was a less-expensive comprehensive coverage option. Second, because these types of excepted benefit plans are exempt from the consumer protections mandated by the ACA, these plans can also do things such as deny coverage due to pre-existing conditions. Third, if an employer offers only these standalone plans and no comprehensive coverage, then lower-income employees who are eligible for subsidized, more comprehensive plans in the ACA marketplaces may not know to look for this comprehensive coverage. Confused by these offerings, and unaware of what is possible for them, employees may make harmful choices for themselves and their families. Even in the best case scenario, where a consumer signed up for one of these plans in addition to a more comprehensive plan offered by the employer, having both may be very confusing for the enrollee to navigate separately, as they would need to figure out two sets of insurance rules, bills, appeal and denial rules, and so on.
Unfortunately, people making coverage decisions related to employer-sponsored plans do not necessarily have robust, neutral, well-informed consumer assistance easily accessible as they navigate these decisions. The proposed bill would make coverage decisions even more complex for employees, without mandating the type of navigator services needed to make informed choices. Without a good place to turn for information—or to go to if they make the wrong choice for themselves and their families—they may be left without the coverage and support they need in a health crisis.
Telehealth can be convenient and helpful when used appropriately as part of comprehensive coverage
Telehealth can be a great way to access care in certain circumstances, when used appropriately, with accessibility embedded, and as part of comprehensive health care access. Telehealth became popular during the pandemic as a way to safely offer care to patients because it avoids the spread of infectious diseases, a specific concern during the pandemic. Telehealth can be especially useful in providing primary care, doing mental health screening, and improving access to preventive health services because telehealth can be cost-effective when a diagnosis does not require physical contact or when physical contact is otherwise challenging or risky. Telehealth can also help to reduce stigma for people accessing certain services such as mental health care or gender-affirming care and can help make people feel safer if they feel threatened when accessing certain services in person.
Telehealth will not solve the most pressing problems concerning inequitable access
Telehealth has been promoted as a great way to provide care for people in rural settings, yet it is more often used to treat people in urban areas—likely because patients and providers in rural areas are less equipped for it due to the lack of reliable Internet service. Telehealth is also more likely to be used by college-educated people with higher incomes, and by white people (see Figures 1 and 2). An exception to this is high usage rates among Indigenous populations: non-Hispanic Native Americans and Alaska Natives are disproportionately likely to use telehealth services, comparable to whites, potentially because the Indian Health Services has a long history of using telehealth and greatly expanded its use during the pandemic. In general, though, usage rates indicate that increasing telehealth usage would not necessarily help to address some of the major inequities we see in our country’s health care system overall—except for the usage rates in Native American and Alaska Native populations.
We do know that telehealth can be useful for people with disabilities who might face challenges getting to facilities in-person based on transportation or accessibility issues, especially in rural areas. However, there is a risk that people with disabilities can also be asked to use telehealth appointments when it may not be appropriate, simply because it is easier on the provider. This might lead to worse health outcomes in some cases, such as when disabled individuals face accessibility challenges with various telehealth platforms and others face difficulty describing their medical condition without a physical exam.
The standalone telehealth plans that employers would offer in response to this legislation are unlikely to lead to the additional investments necessary to advance equity for the simple reason that the legislation has no rules or any incentives for these standalone plans to address these challenges. There are things that can be done to help telehealth services to become more equitable, such as making investments in Internet access, or providing facilitated telehealth services where a medical assistant comes to the patient’s home, helps to set up of the remote appointment, facilitates conversation so that patient needs and provider explanations are mutually understood, and can potentially provide some of the treatment that the provider prescribes. And while Federal law requires nondiscrimination in providing telehealth services, including reasonable modifications to the standard provision of services (such as additional supports before, during, or after the visit) and effective communication practices with disabled individuals, achieving equity in telehealth would require better standards, monitoring and enforcement.
Congress should instead prioritize equitable, affordable, accessible, comprehensive health coverage
Adding standalone telehealth-only plans to the range of pre-tax excepted benefits offered by employers would further exacerbate the problems of the country’s already discriminatory health system. In providing telehealth as a pre-tax benefit, this proposed legislation would remove funds from the tax base that could be used to address public health concerns more democratically and focus attention on advancing equity in the health care system—or even to make some of the investments that would make telehealth more equitable. The nation’s reliance on employer-sponsored health care plans as a way of funding our health care system already results in discrimination against lower-income households, people of color, people with disabilities, and others who have systematically had less access to the employer sponsored system due to no fault of their own—and this proposal does nothing to rectify that.
While many people were very appreciative of telehealth availability and convenience during the pandemic, and the expansion of telehealth has led to some limited improvements in care, neither the majority of patients nor providers want it to replace in-person care in the future. Rather than proposing legislation that would undermine ACA’s progress, Congress instead should be focusing on ways to build on the ACA by expanding comprehensive, affordable, accessible, and equitable coverage to people that addresses the major problems in our health system today.