Tom York, 57, said he appreciates the law’s mandate because until this year the deductible on his plan was $5,000, meaning that without that ACA provision, he and his wife would have had to pay full price for those services until the deductible was met. “A colonoscopy could cost $4,000,” he said. “I can’t say I would have skipped it, but I would have had to think hard about it.”
Now health plans and self-insured employers — those that pay workers’ and dependents’ medical costs themselves — may consider imposing cost sharing for preventive services on their members and workers. That’s because of a federal judge’s Sept. 7 ruling in a Texas lawsuit filed by conservative groups claiming that the ACA’s mandate that health plans pay the full cost of preventive services, often called first-dollar coverage, is unconstitutional.
U.S. District Judge Reed O’Connor agreed with them. He ruled that the members of one of the three groups that make coverage recommendations, the U.S. Preventive Services Task Force, were not lawfully appointed under the Constitution because they were not nominated by the president and confirmed by the Senate.
Mark Rakowski, president of the nonprofit Chorus Community Health Plans, said he strongly believes in the health value of preventive services and likes making them more affordable to enrollees by waiving deductibles and copayments.
But if the mandate is partly eliminated, he expects that competitors would establish deductibles and copays for preventive services to help make their premiums about 2% lower. Then, he said, he would be forced to do the same to keep his plans competitive on Wisconsin’s ACA marketplace. “I hate to admit that we’d have to strongly consider following suit,” Rakowski said, adding that he might offer other plans with no-cost preventive coverage and higher premiums.
The ACA’s coverage rule for preventive services applies to private plans in the individual and group markets, which cover more than 150 million Americans. It is a popular provision of the law, favored by 62% of Americans, according to a 2019 KFF survey.
Spending on ACA-mandated preventive services is relatively small but not insignificant. It is 2% to 3.5% of total annual expenditures by private employer health plans, or about $100 to $200 per person, according to the Health Care Cost Institute, a nonprofit research group.
Several large commercial insurers and health insurance trade groups did not respond to requests for comment or declined to comment about what payers will do if the courts end the preventive services mandate.
Experts fear that cost sharing for preventive services would hurt growing efforts to reduce health disparities.
If it’s left up to individual plans and employers to make these decisions about cost sharing, underserved Black and brown communities that have benefited from the removal of cost sharing will be disproportionally harmed,” said Dr. A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design, who helped draft the ACA’s preventive services coverage section.
One service of particular concern is preexposure prophylaxis for HIV, or PrEP, a highly effective drug regimen that prevents high-risk people from acquiring HIV. The plaintiffs in the lawsuit in Texas claimed that having to pay for PrEP forces them to subsidize “homosexual behavior”to which they have religious objections.
Since 2020, health plans have been required to fully cover PrEP drugs and associated lab tests and doctor visits that otherwise can cost thousands of dollars a year. Of the 1.1 million people who could benefit from PrEP, 44% are Black and 25% are Hispanic, according to the Centers for Disease Control and Prevention. Many also are low-income. Before the PrEP coverage rule took effect, only about 10% of eligible Black and Hispanic people had started PrEP treatment because of its high cost.
O’Connor, despite citing the evidence that PrEP drugs reduce HIV spread through sex by 99% and through injection drug use by 74%, held that the government did not show a compelling governmental interest in mandating no-cost coverage of PrEP.
“We’re trying to make it easier to get PrEP, and there are plenty of barriers already,” said Carl Schmid, executive director of the HIV + Hepatitis Policy Institute. “If first-dollar coverage went away, people won’t pick up the drug. That would be extremely damaging for our efforts to end HIV and hepatitis.”
Having to pay cost sharing for the drug and associated tests every three months under his employer’s health plan would force changes in his personal spending, he said. The retail price of the drug alone is about $2,000 a month.
But York, who’s 54, stressed that reestablishing cost sharing for PrEP would affect people in lower-income and marginalized groups even more.
“We’ve been working so hard with the community to get PrEP into the hands of people who need it,” he said. “Why is anyone targeting this?” (U/Newswise)
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