Alliance Blog

How a federal court ruling could impact preventative services coverage

Equitable access to high-value, appropriate care is core to the mission of the Washington Health Alliance and its 185 multi-stakeholder member organizations. However, a September ruling from a federal judge in Texas on a lawsuit attacking the Affordable Care Act may erode the progress our health care system has made toward that goal.

We are writing to draw needed attention to this ruling in Braidwood Management Inc. et al. vs. Becerra et al. U.S. District Court Judge Reed O’Connor determined a requirement that commercial health plans offer coverage without cost-sharing to services recommended by the United States Preventive Services Task Force was unconstitutional given that the members were independent, subject to no direction or control from the Secretary of Health and Human Services, and as such must be appointed by the President and confirmed by the U.S. Senate.¹

The ACA, signed into law in 2010, set a standard that insurance plans would provide coverage at no cost for the USPSTF’s preventative service recommendations that are graded as “A” or “B.”²  These services including colon and breast cancer screenings, tobacco cessation, diabetes screenings, and broad mental health evaluations for both children and adults.

Much of the focus has been on O’Connor’s other ruling in the case that says requiring coverage of PrEP, a drug that dramatically decreases the transmission of HIV, violates the Religious Freedom Restoration Act. However, his rulings in this case have a broad impact on all preventative care recommended by the USPSTF.

Experts in health care policy acknowledge that the provision requiring coverage at no cost – among the first of the ACA to be enacted – is one of the widest reaching, not only affecting more than 100 million patients but also directly impacting nearly all private health insurance plans, excluding a limited number of grandfathered plans purchased ahead of the law’s passage. ³

It’s been regarded that coverage without cost-sharing for preventative services has increased equitable access to care. A report this year from the Department of Health and Human Services highlights that roughly 150 million Americans with private insurance currently can receive crucial preventative services under the ACA.

In Washington state, it is estimated that 3. 8 million individuals have private health insurance that covers preventative services without cost-sharing.³

While O’Connor has ruled that task force may violate the appointment clause of the Constitution, he has yet to determine a remedy. It is anticipated he will make a decision early next year and the plaintiffs have signaled a desire to see this requirement be lifted.

All recommended preventative services should be kept in place at no out-of-pocket cost for patients. A recent study shows that these services are low-cost and represent a relatively low percentage of total health care costs.⁴ However, the services represent high-value care by often heading off costly, avoidable treatment down the line.

There have been a number of studies that have shown the number of cancer screenings recommended by USPSTF stabilizing or increasing after the passage of the ACA. A 2019 study showed that there was a substantive increase in the utilization of mammography among Black women.⁵

Another 2019 study showed that the rates of colorectal cancer screenings increased among privately insured individuals following the passage of ACA.⁶  Further usage of preventive care recommended by USPSTF was shown in a 2017 study to have the potential for even more cost savings, especially as it relates to tobacco cessation.⁷

While the impact of this lawsuit remains unclear as Judge O’Connor weighs a remedy, in a small survey last month from the Employee Benefits Research Institute, 80 percent of HR professionals surveyed said their companies would not impose cost-sharing should the requirement be lifted. However, 8 percent said their companies would impose cost-sharing and 12 percent responded that it would depend.⁸ 

We strongly believe that the lawmakers who crafted and passed ACA in 2010 were correct in linking coverage requirements to the expertise of the volunteer members of the USPSTF, all of whom are the most respected physicians and clinicians in their fields. Should the plaintiffs prevail, legislative efforts should be taken to address the Constitutional concerns to maintain USPSTF’s role and these vital services.

Preserving the coverage of evidence-based preventative services without cost-sharing is essential to equitable, appropriate care for all Washingtonians.

References:

1. Braidwood Managment Inc. et al vs. Xavier Becerra et al. (U.S. District Court Northern District of Texas September 7, 2022).
2. Coverage for Preventive Health Services At Risk in New Court Decision. (2022, September 15). O’Neill. https://oneill.law.georgetown.edu/coverage-for-preventive-health-services-at-risk-in-new-court-decision/
3. ‌ Access to Preventive Services without Cost-Sharing: Evidence from the Affordable Care Act. (n.d.). https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf
4. The Impact of Covering Select Preventive Services on Employer Health Care Spending. (n.d.). Retrieved November 3, 2022, from https://www.ebri.org/docs/default-source/fast-facts/ff-444-preventiveservices-20oct22.pdf?sfvrsn=8efb382f_2
5. ‌ Fazeli Dehkordy, S., Fendrick, A. M., Bell, S., Kamdar, N., Kobernik, E., Dalton, V. K., & Carlos, R. C. (2019). Breast Screening Utilization and Cost Sharing Among Employed Insured Women Following the Affordable Care Act: Impact of Race and Income. Journal of Women’s Health, 28(11), 1529–1537. https://doi.org/10.1089/jwh.2018.7403
6. ‌ Bhandari, N. R., & Li, C. (2019). Impact of The Affordable Care Act’s Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey. Healthcare, 7(1), 36. https://doi.org/10.3390/healthcare7010036
7. Maciosek, M. V., LaFrance, A. B., Dehmer, S. P., McGree, D. A., Flottemesch, T. J., Xu, Z., & Solberg, L. I. (2017). Updated Priorities Among Effective Clinical Preventive Services. The Annals of Family Medicine, 15(1), 14–22. https://doi.org/10.1370/afm.2017
8. Will Employers Introduce Cost Sharing for Preventive Services? Findings From EBRI’s First Employer Pulse Survey. (n.d.). Retrieved November 3, 2022, from https://www.ebri.org/docs/default-source/fast-facts/ff-445-pssurvey-27oct22.pdf?sfvrsn=52f4382f_2