By limiting preventive care, ACA ruling a ‘grave disservice’ to patients

Key takeaways:

• Experts argued preventive services are the “heart” of the ACA as they improve health outcomes and reduce disparities.
• Services like screenings for cancer and BP may now face significant deductibles and copays.

Last month’s Affordable Care Act ruling stands as a “grave disservice” by threatening access to hundreds of clinical preventive services that millions of Americans have come to rely on, experts argued.

“I think it is a partisan opinion that fundamentally misunderstands the law, science and public health,” Lawrence O. Gostin, JD, Founding Linda D. & Timothy J. O’Neill Professor of Global Health Law and director of the O’Neill Institute for National and Global Health at Georgetown University, told Healio. “Congress enacted the ACA to improve health coverage, especially for preventive health services.”

The plaintiffs of the case, Braidwood Management v. Xavier Becerra, argued that the ACA’s requirement to provide free preventive care is unconstitutional. In addition, they contended that requiring certain services, including HIV preexposure prophylaxis, to be covered at no cost may violate employers’ religious rights.

The federal judge in Texas, U.S. District Judge Reed O’Connor, agreed with some of the arguments and ruled that the mandate for insurers to cover certain preventive services given “A” or “B” recommendation ratings by the U.S. Preventive Services Task Force at no cost cannot be enforced.

The ruling does not apply to certain services that are recommended by other agencies, including the Health Resources and Services Administration (HRSA) and the CDC’s Advisory Committee on Immunization Practices (ACIP).

Still, the accessibility of preventive services — the “heart” of the ACA — could now be significantly diminished despite demonstrating improvements in health outcomes and equity, Gostin and Abbe R. Gluck, JD, a professor of law at Yale Law School, wrote in a viewpoint published in JAMA.

“The word ‘prevention’ is mentioned dozens of times in the ACA,” Gostin said. “Prevention services are vital to keep people healthy and safe. It is also cost effective. By limiting access to key clinical prevention services, the court has done a grave disservice to the U.S. population.”

He acknowledged that while it is not entirely clear which services will be affected by the ruling, “unless it is overturned on appeal, patients may have to pay hefty deductibles and copays for a wide number of screenings and services, including screenings for cancer, blood pressure, sexually transmitted diseases and much more.”

The ruling has already started to impact the medical community, according to the authors, causing confusion among clinicians over what services remain covered without costs.

Additionally, while patients with “sufficient means” may not be deterred by increased financial costs, “there is evidence that working-class U.S. residents will avoid health care if they have to pay,” they wrote.

The Biden administration has appealed the ruling, but it may be months or years before a final resolution is made, according to the Kaiser Family Foundation.

ACA challengers have also appealed the decision.

“At the appellate level, the challengers could once again attempt to invalidate all 200 preventive services, putting the entire ACA preventive clinical services regime at risk,” Gostin and Gluck wrote. “The case will first be heard by the conservative federal Fifth Circuit Court of Appeals in Texas, and then, most likely, the Supreme Court, which has been increasingly sympathetic not only to religious freedom claims, but also to attempts to claw back public health and safety authorities.”

The authors added that, on appeal, any of the ACA’s preventive services — including those designated by entities such as HRSA and ACIP — “will be fair game and could be eliminated.”

In a related editorial, Gregory Curfman, MD, an assistant professor of medicine at Harvard Medical School, and Kirsten Bibbins-Domingo, PhD, MD, MAS, an Endowed Professor of Medicine at the University of California, San Francisco, wrote that O’Connor’s ruling seemed to be “explicitly designed to eliminate the valuable role the USPSTF has played in preserving the nation’s health” by favoring arguments based on religious grounds regarding services like preexposure prophylaxis.

“The ultimate outcome in this case will have critically important health consequences for the U.S. at a time when life expectancy in the U.S. continues to decline at an alarming rate, and large gaps in health based on income and accessibility continue to grow,” they wrote.

References:

• Braidwood Management v. Xavier Becerra. https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.114.0.pdf. Accessed April 19, 2023.
• Curfman G, Bibbins-Domingo K. JAMA Netw Open. 2023;doi:10.1001/jama.2023.6605.
• Gluck A, Gostin L. JAMA Netw Open. 2023;doi:10.1001/jama.2023.6584.
• No-cost preventive services are now in jeopardy. Here’s what you need to know. https://kffhealthnews.org/news/article/four-things-to-know-about-braidwood-court-ruling-affordable-care-act/. Published April 7, 2023. Accessed April 19, 2023.