Millions could lose no-cost preventive services if SCOTUS upholds ruling

A study by the Stanford Prevention Policy Modeling Lab (PPML) finds that almost 30% of privately insured individuals in the United States, or nearly 40 million people, use at least one of the free preventive health services guaranteed under the Affordable Care Act (ACA).

But those services are now under threat by an ongoing legal challenge.

On April 21, the Supreme Court will hear arguments in Kennedy v. Braidwood Management Inc. to decide whether to uphold the ruling of a Texas district court that the ACA preventive services mandate was unconstitutional.

The ACA requires that private insurers cover specific preventive services at no cost to patients, such as blood pressure, diabetes and cholesterol tests, and cancer, HIV and hepatitis C virus screenings. One set of services mandated for no-cost coverage follows recommendations from the U.S. Preventive Services Task Force (USPSTF), which bases these recommendations on strong evidence of effectiveness in improving health through prevention and early detection of disease. The legality of mandating USPSTF-recommended services is the focus of the current case.

Who uses preventive services?

The PPML team from Stanford School of Medicine and Harvard T. H. Chan School of Public Health looked at claims data from privately insured individuals in the United States, state by state. They determined how many people received, at no cost, any of the 10 services most likely jeopardized by Braidwood.

The study published in JAMA Health Forum found that almost 30% of privately insured individuals, and almost half of privately insured women, use at least one of the 10 services at no cost. They found that 13 states have at least 1 million recipients of these free services—including 3 million (30%) people in Texas, where the case originated.

“Preventive services are essential health care. Eliminating guaranteed free access to these services would likely lead to lower use of evidence-based screening and treatment interventions, and worse health outcomes,” said Josh Salomon, Ph.D., a professor of health policy and director of the Stanford PPML, and senior author on the study.

The threat to preventive services

A previous study indicated that around 150 million U.S. individuals have employer-sponsored insurance that makes them eligible for the free services mandated under the ACA. Another study looked at five services potentially affected by Braidwood and estimated that 10 million people received those services. The new Stanford-led study is the most detailed and comprehensive analysis to date on the potential reach of a Braidwood decision, looking at a broad array of jeopardized services and including analysis of who receives these without cost-sharing.

In the Braidwood case, a key part of the Supreme Court’s decision will be to evaluate the claim that the mandated coverage of USPSTF-recommended services violates the Appointments Clause of the Constitution, which declares that “officers of the United States” be appointed by the President and then confirmed by the Senate. The USPSTF health experts who recommended the preventive services are not appointed by the President.

In the original Texas case, the plaintiffs also asserted that the federal mandate to cover HIV prevention medication violated their religious rights.

The Stanford study focused on a cohort of 16.1 million employee-sponsored health insurance enrollees in the MarketScan database, representing 130.9 million enrollees nationwide. The team identified preventive services most likely to be impacted by Braidwood due to having new or revised USPSTF recommendations since enactment of the ACA.

The services included statin use to prevent cardiovascular disease, pre-exposure prophylaxis for HIV, medication to reduce breast cancer risk, and new or expanded screenings for breast cancer, cervical cancer, colorectal cancer, lung cancer, hepatitis B virus infection, hepatitis C virus infection, and HIV infection. Among the 39.1 million individuals nationally who received any of these services without cost-sharing, the most widely used services were screenings for cervical cancer and hepatitis C virus and HIV infections.

“The ACA preventive services mandate has been consistently popular in public opinion polls,” the researchers said in their study.

“The decision in this case will be important for millions of people with private insurance, across all states, who are currently benefiting from free preventive services thanks to the ACA mandate,” said lead author of the study, Michelle Bronsard, MSc, a research fellow at the Stanford Institute for Economic Policy Research (SIEPR) and incoming Ph.D. student at Stanford Health Policy.

The other PPML members and co-authors of the study were Adrienne Sabety, Ph.D., assistant professor of health policy at Stanford and a SIEPR faculty fellow; Minttu Rönn, Ph.D., a research scientist at the Harvard T.H. Chan School of Public Health; and Nicole Anne Swartwood, MSc, a research analyst at the Harvard T.H. School of Public Health.