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Nearly 20 activists from Indivisible York stood outside Rep. Scott Perry’s district office in Springettsbury Township on Thursday afternoon to protest the congressman’s vote in favor of the Republican-sponsored American Health Care Act one week before.

During the hourlong rally at the office of Perry, R-Dillsburg, York City activist Marta Peck said “Trumpcare 2.0 is a monstrosity,” pointing especially to the provision that eliminates the need for insurance to cover 10 "essential health benefits."

If the bill passes the Senate and is signed into law, “insurance companies can again sell cheap insurance that covers little to nothing,” Peck said.

Across the country, critics of the Republican health care plan passed by the House have mostly focused on how it might harm Americans with pre-existing health conditions and poor and disabled people who rely on Medicaid — two vulnerable, but defined, populations.

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But another change might have more far-reaching effects: eliminating the Affordable Care Act’s “essential health benefits,” or EHBs. That shift could affect almost everybody, including the 156 million Americans who receive health coverage through their employers.

Under the ACA, health plans sold to individuals and small groups (employers with 50 or fewer employees) must include 10 essential benefits: emergency services, habilitative and rehabilitative services, inpatient care, outpatient care, maternity and newborn care, mental health and addiction treatment, lab tests, preventive care, prescriptions and pediatric services, including oral and vision care.

Protest: Leslie Hall, one of Perry’s Harrisburg-based constituents, said it is “absolutely nuts” that maternity and newborn care could potentially be deemed nonessential health care benefits at the state level and asked why legislators are trying to raise more barriers to motherhood.

Hall, 22, also said she was surprised that Perry and other lawmakers are leaving it up to states to decide whether addiction treatment is an EHB in the midst of an opioid epidemic.

Under the current law, plans offered by larger employers do not have to include all 10 essential benefits. However, if the plans cover any EHBs, they cannot impose annual or lifetime limits on reimbursements for those expenses.

The House GOP plan would eliminate the federal mandate under the ACA and instead give states the power to determine what health plans sold on the individual and small group market must cover.

Otto Tomasch, of York City, said he showed up at Perry’s office to protest the “mean-spiritedness” of the AHCA and the way the bill treats those on the margins of society.

The bill provides tax cuts for the wealthy while taking away benefits that many of those who are less fortunate need “to make it through the day,” Tomasch said.

Tomasch said the idea behind the AHCA to provide states with more control over health insurance reminds him of the Civil Rights era, when there were obvious discrepancies between states, and he said the AHCA “beckons to the same unevenness.”

Many at the rally admitted the ACA has flaws, but they said lawmakers should be working to improve it instead of replace it.

“The ACA isn’t perfect, but it’s still better than nothing,” Hall said.

After several people spoke of how they and their loved ones would be affected by a repeal of the Affordable Care Act, about a dozen Indivisible York members laid down on the wet lawn in front of Perry’s office to hold a “die-in” protest.

While they lay still, with fake tombstones and signs advocating against the AHCA above their heads, one member counted out 24 seconds — each second representing 1 million people who stand to lose coverage under the AHCA, according to Indivisible York.

Counter-protest: A handful of members from Grace Fellowship were also outside Perry’s office holding signs of support for the three-term congressman.

Diana Jordan, of Windsor Township, said she was there to counter-protest Indivisible York’s rally and remind people that there are two sides of the issue.

Jordan said she agrees with House GOP members that states should be vested with the authority to determine health care legislation and mandates as state representatives and senators are more in tune with their constituent bases on the issue.

Jordan said she believes health insurance should be put back on the free market, a move that Barbara Smith, of Jackson Township, said would drive down health insurance premium costs while opening up more choices to health care consumers.

Smith also said she would like to see health care providers be allowed to sell plans across state borders to further drive down premiums.

Flexibility for insurers: Under the AHCA, insurers would be free to sell cheaper, bare-bones plans to young and healthy consumers who don’t think they’ll need certain benefits. Many of those consumers would end up paying less for their health insurance.

Supporters of the GOP plan say it makes little sense to force people to pay for services they don’t want. Why, for example, should a single man have to pay extra for a policy that covers maternal health care?

“That is a commandeering approach to health insurance which those of us on our side find objectionable,” said Edmund Haislmaier, senior health policy research fellow at the Heritage Foundation, a conservative think tank.

But for people needing broader coverage, the change likely would mean higher premiums and fewer choices. It also would force people who opt for bare-bones coverage to pay out-of-pocket for services they unexpectedly need.

The change would affect even those who receive coverage through their employers, because the prohibitions on annual and lifetime caps are tied to the essential benefits.

A late amendment to the GOP bill, which now moves to the Senate, would allow large employers to choose benefit packages from any state instead of being bound by the rules in their home state. For example, an employer looking to cut its insurance costs could choose to follow the rules of a state that had made hospitalization nonessential. The employer could then impose annual or lifetime limits on reimbursement for hospitalization — something barred under the ACA.

“The quality of health insurance will vary widely from state to state, as would the depth of those services,” said Michael Williams, director of the Center for Health Policy at the University of Virginia.

Opposition: The Republican proposal has drawn opposition from many prominent health care groups, including the American Medical Association, the American Hospital Association, the American Academy of Family Physicians, the National Alliance on Mental Illness and the American Diabetes Association. Some Republicans, including Sen. Susan Collins of Maine, have objected to the elimination of some EHBs, especially addiction treatment services at a time when her state, like many others, is facing a crisis of opioid addiction.

Even the insurance industry, which might be expected to welcome the increased flexibility it would have under the GOP plan, has been circumspect about the question of EHBs. Kristine Grow, a spokeswoman for America’s Health Insurance Plans, the lobbying arm of the commercial health insurance industry, said the group has taken no position on whether they should be scrapped.

Most health care policy analysts are adamantly opposed to scrapping the essential benefits mandate, fearing a return to pre-ACA days when most plans offered on the individual market provided bare-bones coverage or high deductibles and copayments.

“The essential health benefits made insurance coverage really meaningful,” said Karen Pollitz, a senior health policy fellow at the Henry J. Kaiser Family Foundation. “It really took a lot of junk off the market, and there was a lot of it.”

Pollitz said the elimination of the essential health benefits would cause a cascade of negative effects, both for people who opt to purchase the bare-bones plans and those who opt for more comprehensive coverage.

For the former, Pollitz said, the change “would make monthly premiums less expensive, but it adds to the risk that if something did happen that they didn’t anticipate, they’d have to pay for their health care out of their own pockets.”

For the latter, premiums would go up, because insurers could no longer spread risk across a broader pool of beneficiaries.

As an example, Pollitz pointed to maternal health care, which most pre-ACA individual policies did not offer. If insurers were not required to include it, only pregnant women or women who hoped to become pregnant would opt to pay more for policies that included that benefit. Because nearly all of them likely would use it, the premiums for such policies would be extremely high, probably “pretty close to the cost of labor and delivery themselves,” Pollitz said.

Pollitz and other critics also contend that eliminating the essential health benefits would undermine the popular ACA provision requiring health insurers to accept policyholders with pre-existing health conditions.

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