By Surabhi Dangi-Garimella, Ph.D.
In 2010, the Affordable Care Act (ACA) required a majority of private health plans to cover preventive healthcare services without any out-of-pocket costs to enrollees: meaning no co-pay or deductible. However, a new ruling by a Texas judge has the potential to jeopardize preventive care services for millions of people.
What is the Preventive Care Coverage Ruling?
Judge Reed O’Connor of Texas’ Northern District Court has ruled the ACA’s provision of coverage for US Preventive Services Task Force (USPSTF)-recommended services as unconstitutional because task force experts are volunteers and are not confirmed by the Senate—this, according to the judge, invalidates their coverage recommendations.
The services in question include new recommendations or updates made by the USPSTF after March 2010 (when the ACA was implemented). However, it will not affect:
- Vaccine recommendations made by the Advisory Committee on Immunization Practices (ACIP)
- Women’s preventive health services made by the Health Resources and Services Administration (HRSA)
- Services for children and young adults recommended by Bright Futures.
Also, if sustained, the ruling may not be implemented till the new coverage year.
Services That May Require Cost Sharing
Regular mammography and cervical cancer screens for women won’t require cost sharing because those recommendations preceded the ACA. However, the following recommendations may require patient cost sharing in the future:
- Colorectal cancer (CRC) screening for 45–49-year-olds: the USPSTF updated CRC screening age recommendation from 50 years to 45 years in 2021. Those in the 45-49 age group may face a cost burden for screening.
- Lung cancer screening recommendation was updated in 2021: low-dose CT scan for 50-80 years with a 20-pack year history who currently smoke or have quit in the past 15 years may face out-of-pocket costs.
Information on several other preventive services recommended by the USPSTF after March 2010 that may require cost sharing can be found here.
Access to PrEP in jeopardy: Health plans may either completely drop coverage of PrEP, which is an HIV-prevention treatment, or require cost sharing. This could introduce a cost burden on those taking branded PrEP medications that are substantially more expensive (up to $2,000 monthly) than generic meds ($60 monthly), in addition to the costs associated with lab tests and doctor’s visits.
Some States and Insurers Have Vowed to Continue Providing Access to Preventive Services
The Governor of Illinois, J. B. Pritzker has said that the Illinois Department of Insurance will be taking steps to ensure preventive services coverage for the state’s residents. Michigan Governor Gretchen Whitmer has also announced plans to work with the state’s insurers to ensure continued access to preventive care for those living in the state while looking into alternate options as well.
A few private health insurance companies have said they will continue to cover preventive services despite the ruling. Blue Cross Blue Shield Association has announced that their coverage of preventive services will not change with this ruling. AHIP, which represents health insurers, has assured enrollees that their coverage will not see any immediate change. Meanwhile, Democratic leaders in the House and Senate have requested health insurers to provide information on their plans in reaction to the ruling and whether they would continue to provide coverage for all recommended preventive services without cost-sharing until till the time that all appellate review is done.
If this ruling isn’t overturned, it will reverse substantial gains that followed ACA implementation, including access to preventive services without cost sharing for 150 million individuals enrolled in private health insurance. Access to prevention services without cost sharing has improved colon cancer screening, vaccinations, use of contraception, and chronic disease screening and prevention—this progress now hangs in balance.
Surabhi Dangi-Garimella, Ph.D. is a biologist who provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.
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