Texas judge gut punches preventive care

by Lisa Jarvis

A federal judge in Texas ruled last week that insurers no longer have to cover some preventive services that have long been included under the Affordable Care Act. It’s a frustrating decision that will likely hurt Americans’ health. At least some insurers are likely to take the opportunity to cut back on lifesaving care. About 60% of privately-insured people — that’s about 100 million Americans — receive preventive care under the ACA. 

The last thing the U.S. needs is more barriers to basic health care. In December, the CDC said that life expectancy in the U.S. hit its lowest point in over two decades. And it’s not just adults dying younger — kids are too. Attacking preventive care will only worsen this long-term trend, which easily predates the COVID pandemic. 

There’s been some confusion around which services the ruling affects. The holding by Judge Reed O’Connor only applies to recommendations made by the U.S. Preventive Services Task Force, an independent panel of doctors, after 2010, as executive vice president for health policy at KFF Larry Levitt explained in a press briefing. But that puts coverage of a swath of more recently recommended services at risk, including screening for lung and skin cancer, preventive drugs for women at high risk of developing breast cancer, coverage of cholesterol-lowering drugs and blood pressure screening. 

The decision is also a blow to the Centers for Disease Control and Prevention’s goal of ending HIV in the U.S. by 2030. A cornerstone of the agency’s strategy is to increase use of PrEP, medicine that is more than 99% effective at preventing transmission of the virus that causes AIDS. Now, insurers will no longer have to offer those pills, or the lab tests and follow-up visits related to accessing them. And while many insurers are expected to continue covering the medicines, they might now require patients to share in the cost of treatment, putting them out of reach. 

A recent study found that PrEP currently prevents some 3,200 HIV transmissions per year among men who have sex with men. According to the authors, the Braidwood ruling could translate into at least 2,057 more HIV infections in the U.S. in the first year after the ruling alone. 

KFF’s Levitt noted a few key areas of preventive health care are not affected by the ruling, which only extends to the purview of the independent U.S. Preventive Services Task Force. That includes any recommendations made by ACIP, the CDC-housed body that provides vaccine guidance, or women’s health guidelines developed by the Health Resources and Services Administration. 

But that doesn’t mean those services aren’t still at risk. Appeals to the ruling are expected on both sides of the case. The plaintiffs, Braidwood Management LLC, don’t only want to stop providing insurance coverage for things like PrEP; they want to stop covering other critical preventive care, like birth control and HPV vaccines, arguing that they encourage behavior banned by the Bible, as my Bloomberg Opinion colleague Noah Feldman has explained. 

If they’re successful, many people will end up paying more for basic health care. And research shows that putting a price tag on care, whether that’s a $25 copay for a flu vaccine or $100 for a colonoscopy, prompts many people to forgo it. “Patients are their own worst doctors,” says John Graves, associate professor of health policy at Vanderbilt University School of Medicine. When people encounter an out-of-pocket cost, “they cut back indiscriminately,” he says. “They’re not differentiating what’s low value and high value, they just cut back.”  

That phenomenon is supported by a growing body of evidence so compelling that it elicits little debate among health policy scholars, notes Graves, who previously worked on the team that helped estimate the cost of the ACA. For example, one study found that increasing the cost of a drug by just $10 resulted in a 23% drop in the drug’s use — and an estimated 33% increase in monthly mortality. A Morning Consult poll found that 40% of adults would not pay for most of the services offered by ACA, and half would forgo services like HIV screening, smoking cessation treatment, and depression screening. 

What a shame that would be. Prevention is a powerful tool in maintaining and improving the health of the population. A recent report from the American Cancer Society drove that point home: Cancer deaths in the U.S. have dropped by a third since 1991. Services that have been offered for free under the ACA — like smoking cessation and screening for breast, colon and prostate cancers — were key to that progress. 

Insurers have an incentive to continue offering such preventive services free of copays, even if they no longer have to — prevention is cheaper than treating disease. And they’ve likely passed on some of the costs of these “free” services in the form of higher premiums, which have risen 58% since 2010 for people with employer-sponsored plans. 

Nonetheless, weakening the ACA will allow insurers to charge even higher premiums coupled with more and higher copays. 

If Braidwood’s efforts to expand the scope of preventive care coverage are successful, it will be a disastrous outcome for health care in the U.S. It’s a component of ACA that we’ve all come to take for granted, whether its sailing through a checkup without taking out a credit card, rolling up our sleeves for a free flu vaccine, or filling a prescription for cholesterol-lowering statins. Making these services free isn’t just about saving Americans money — it’s about making it as easy as possible for people to be healthier. That, in turn, saves both money and lives. 

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.