Court decision endangers free preventive care for cancer, HIV, other conditions

Originally written by Erin Durkin and published by National Journal on 4/4/23.

Ajudge’s decision in Texas to gut some core Obamacare provisionscould leave patients without access to free preventative services thataim to prevent HIV, hepatitis C, and cancer. But both health careadvocates and insurers are reassuring patients there will not be changes—yet.

The U.S. government also has appealed the ruling.

The American Cancer Society Cancer Action Network is concerned confusionabout the ruling could discourage patients from seeking treatment.

“Even if the rules aren’t changing you could see where somebody may haveinadvertently heard something or misconstrued something … and it ends upwith people not getting the recommended services that they want to get,” saidAnna Howard, policy principal on access to care for the group.

“We want to make sure that we can do whatever we can to make sure that peopleare getting the screenings that they need.”

The ruling doesn’t impact mandates on vaccines and contraception coverage, butit does affect a slew of services that aim to prevent HIV, hepatitis C, cancer, andother conditions.

The ruling blocks the federal government from requiring private insurers tocover services recommended by the U.S. Preventive Services Task Force withoutpatient cost-sharing.

Health-policy experts say the ruling applies to recommendations made on orafter March 23, 2010, the passage date of the Affordable Care Act. The servicesaffected also need to be graded “A,” meaning there is high certainty there will bea substantial net benefit from the service, or “B,” where there is at least amoderate certainty that the net benefit is moderate to substantial.

The ACA required group and individual health plans to cover both “A” and “B”recommendations and plans were not allowed to impose cost-sharing onpatients.

Larry Levitt, an executive vice president for health policy at the Kaiser FamilyFoundation, said in a web event following the ruling that “it’s very likely thatinsurers will still cover these preventive services” but that “insurers may verywell charge patient cost-sharing for these services.”

Under Obamacare, pre-exposure prophylaxis or PrEP was covered without costunder private health insurance, but now insurers could drop the coverage orimpose a cost to patients. District Court of Northern Texas Judge ReedO’Connor also singled out the PrEP coverage mandate as violating the plaintiffs’rights under the Religious Freedom Restoration Act.

Soon after the court issued its verdict, the insurance trade organization AHIPreleased a statement saying “there will be no immediate disruption in care orcoverage.”

James Gelfand, president of the ERISA Industry Committee, does not expectcoverage changes in the near future, noting that the terms of plans are set for ayear.

“We also just don’t think that there is a hunger amongst employers, or reallyinsurance companies either, to reimpose co-pays for stuff that is supposed toprevent higher cost interventions later,” he said. “If you think about the differentthings that have been selected by [the task force], most of it’s not controversial.” 

Gelfand said there is an “exceedingly small group of religious employers” thatmay have issues covering PrEP. But most employers aren’t religious and “they’rethinking about math,” he said.

“Will paying for this upfront lead to lower costs later?” he said. “The answer forthe vast majority of stuff that [the task force] has designated as ‘A’ and ‘B’ is yes.”

Kaiser Family Foundation experts said changes aren’t necessarily going to beimmediate as well. But if the ruling stands, “over time, millions of people couldend up paying more for preventive care and some may lose access to certainservices,” according to a Q&A the organization released on the ruling.(https://www.kff.org/policy-watch/qa-implications-of-the-ruling-onthe-acas-preventive-services-requirement/) 

Jesse Milan, president and CEO of AIDS United, said patients shouldn’t bank onthe word of insurance companies that PrEP will continue to be accessible at nocost in the long term.

“If this decision has a long-term impact, we cannot rely on health-insurance companies to make a long-term decision that they will continue to offer PrEP,”he said. “Particularly with regard to co-pays and costs, the impact could be verysubstantial for marginalized and disenfranchised people who most especiallyneed to have access to PrEP.”

There are already racial disparities when it comes to who can access PrEP, andthe court decision exacerbates the problem, Milan said.

Pulling data from 2020 and 2021, an AIDSVu report found that Black people represented14 percent of PrEP users but 42 percent of new HIV diagnoses. White peoplerepresented 65 percent of PrEP users and 26 percent of new diagnoses. AIDSVuis presented by Emory Unversity’s Rollins School of Public Health with GileadSciences and the university’s Center for AIDS Research.(https://aidsvu.org/prep-use-race-ethnicity-launch 22/#:~:text=Black%20people%20represented%2014%25%20of%20PrEP%20users%2C%20but%2042%25 ,26%25%20of%20new%20HIV%20diagnoses.) 

“We cannot and should not close any door that provides a way for people to haveaccess to PrEP, and this is closing a very important door. … We need thisdecision to be overturned and for a national PrEP program to be put in place,”Milan said.

President Biden’s 2024 budget calls for a new mandatory program to providePrEP for free to the uninsured and underinsured. The budget estimates theprogram would cost $9.8 billion over 10 years.

It’s not just newer services recommended since 2010 that could be on thechopping block. The task force has also frequently updated recommendationsthat predate the Affordable Care Act.

“There are recommendations that get re-released over time and the language inthe recommendation can be updated with additional nuance or changes in someof the subtleties of to whom the recommendation applies,” said ElizabethKaplan, director of health care access at Harvard Law School’s Center for HealthLaw and Policy Innovation.

Kaplan pointed to recommendations for hepatitis C screenings as a particularconcern. Currently, the task force’s recommendation is to screen all adults ages18 to 79.

“Before March of 2010, the [task force] recommended screening only adults whoare at high risk for hepatitis C,” she said. “Because before March of 2010, thetreatment options for hepatitis C were far more limited than they are today. Sothe [task force] is regularly reviewing the state of scientific evidence, drugs thathave FDA approval, things of that nature, and they re-release recommendationsor they revisit recommendations.”

There is a lot of new research, technology, and information since the AffordableCare Act was first enacted, said ACA’s Howard. She pointed to the updatedrecommendations for colorectal cancer screening, saying that some patientscould lose coverage of the most up-to-date recommendations while others couldkeep coverage for those benefits but only if they pay a portion of the cost.

“The American Cancer Society lowered their minimum age of screeningguidelines down to 45 because they saw the research of younger people gettingcolorectal cancer, and then the [task force] followed suit in 2021,” she said. Butthe recommendation before 2010, which is from October 2008, starts screeningsat age 50.

“You miss out on the most up-to-date research in terms of who should bescreened and what should be covered when you go back and look at therecommendations that were in place as of the date of the Affordable Care Act,”Howard said.