Last week, a federal judge in Texas ruled that some Affordable Care Act (ACA) mandates cannot be enforced, including those that require health insurers to cover preventive care, including certain cancer screenings at no cost to the patient.
The ACA relies on three panels of health experts to advise the government on what preventive services insurers must cover: the Advisory Committee on Immunization Practices (ACIP) for vaccines and immunizations, the U.S. Preventive Services Task Force (USPSTF) for general adult preventive services and screening and the Health Resources and Services Administration (HRSA) for children’s and women’s preventive services and screenings.
Under the ACA, any preventive service receiving a Grade A or B from the USPSTF (Task Force) must be covered at 100% by most health insurers. U.S. District Judge Reed O’Connor struck down the use of these recommendations, saying that the USPSTF does not have the constitutional authority to dictate what benefits health insurers must cover.
Since it was established in 1984, the Task Force has issued dozens of recommendations with an A or B rating. Because of this ACA provision, those services are currently available to patients for free. In line with expectations, research shows that eliminating patient costs boosts the uptake of preventive services, ultimately saving lives and reducing health disparities.
Judge O’Connor’s decision applies to Task Force recommendations published on or after March 23, 2010—the day the ACA was signed into law. While many USPSTF recommendations were made prior to that date, nearly all have been updated or expanded in recent years. The Judge’s ruling would effectively make the coverage recommendations from 13 years ago permanent. This is concerning, because those guidelines were based on research and evidence before that time, much of which is now outdated. Cancer-related interventions that would be impacted by this ruling include BRCA genetic counseling and testing, mammograms, pap smears and colorectal and lung cancer screenings.
Affect on High-Risk Screening & Preventive Care
It is important to note that USPSTF guidelines only apply to preventive services for the “general population.” High-risk screenings and preventive care are not covered by the USPSTF. As a result, services like breast screening MRIs, colonoscopies before the age of 45 and risk-reducing surgeries are not affected by this ruling; they are already subject to cost-sharing (meaning deductibles, coinsurance and copays apply).
Timeline for Changes
The Justice Department filed a notice of appeal almost immediately following Judge O’Connor’s ruling. An appeal will take a year or more. After that, the case would likely be a candidate for Supreme Court review, which will further extend the process. This timeline could be accelerated if the ruling is not paused while it works its way through the appeals process, but this is unlikely.
What ultimately happens will determine whether many Americans will continue to have access to certain “free” preventive care. Employers and insurers may maintain zero-dollar coverage for a number of preventive services, because people appreciate the benefits and preventive care is a smart investment. Unfortunately, any return of cost-sharing for preventive services will disproportionately affect underserved populations, hindering access to care.
A Possible Fix
Congress has the ability to remedy this. Instead of relying on the USPSTF to determine coverage of preventive services, it could give authority to the Secretary of Health and Human Services. This would require broad bipartisan support, however, and that is something that has been hard to come by in regard to the ACA.
Stay tuned for updates as this case wields its way through the appeals process.
- Judge Strikes Down Required Coverage of Preventive Care—Cancer Screenings, Pregnancy, Medications and More