Preventive services mandate can be improved, but eliminating it isn’t the answer

Over the past 12 years since the Affordable Care Act became law, individuals, business groups, and state officials who object to one or more of its provisions have filed a lengthy list of mostly unsuccessful lawsuits seeking to have part or all of it declared unconstitutional by the courts. The latest legal challenge involves the requirement that private health insurers cover without patient cost-sharing all evidence-based preventive services, defined as more than 100 services recommended by the Advisory Committee on Immunization Practices, the U.S. Preventive Services Task Force, Bright Futures, or the Women’s Preventive Service Initiative. When I went to my family doctor last month and received screening tests for colorectal cancer, high blood pressure, and cholesterol, these tests were all covered under the ACA’s preventive services mandate. When I take my kids to receive their school-required vaccinations, those shots are fully covered too. The same goes for the costs of clinicians counseling pregnant patients about healthy weight and weight gain to prevent complications such as gestational diabetes, and similar counseling for to midlife women (aged 40 to 60 years) to maintain weight or limit weight gain to prevent obesity.

Why would anyone have a problem with requiring insurers to cover preventive services? Some employers have religious or ideological objections to paying for birth control and sterilization, preexposure prophylaxis for HIV prevention, or testing for sexually transmitted diseases. Others might oppose the increased employer or government contribution to insurance premiums that may result from mandating that these services be covered, though in reality the types of health care that drive up premiums tend to be pricey procedures and medications such as the Alzheimer’s drug Aduhelm, whose initial projected price of $56,000 per year drove the highest-ever increase in Medicare premiums from 2021 to 2022.

Ensuring that patients can afford preventive services is only the first step toward getting them done. Only about two-thirds of eligible adults are up-to-date on colorectal cancer screening, for example, and a much lower percentage of current or past heavy smokers over age 50 have been offered or received lung cancer screening. Behavioral health preventive services such as screening for depression, intimate partner violence, and unhealthy alcohol use can be difficult to fit into clinical practice workflows that rely on dysfunctional electronic health records (systems that are optimized for billing rather than patient care).

The narrow focus of the ACA’s preventive services mandate on health care services also leaves out other private and public programs that can have large benefits on disease prevention and care. For example, the final report of the National Clinical Care Commission included population-level diabetes prevention recommendations involving the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, and the Department of Housing and Urban Development. A related analysis article in Health Affairs bemoaned the fragmented state of US health care and policy that has stalled progress in preventing and controlling type 2 diabetes:

At the population level, fragmentation and lack of shared population health goals across stakeholders mean that there is no ownership for large segments of the population who are at risk for or have diabetes. Payers carry the liability for the health service costs of their beneficiaries and can track utilization. Enrollee churn reduces payers’ incentives to take on long-term responsibility or investments in higher-quality preventive services for which returns are only realized in the long term. … Similarly, the movement of people between health systems undermines incentives for long-term, high-value care.

So you’ll get no pushback from me if you observe that there are lots of flaws and loopholes in the preventive services mandate (beginning with the fact that it doesn’t even apply to half of Americans who are either publicly insured or uninsured). But getting rid of it is throwing the baby out with the bathwater: an exceedingly dumb and harmful proposition that would result in more preventable illness and poorer quality of life for millions of Americans.

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