ACA ruling on preventive care leaves healthcare providers in limbo

The healthcare industry is in limbo following a decision by a Texas court to strike down a provision in the Affordable Care Act that requires free access to certain preventive health services.

Health plans across the country are no longer required to fully cover several services, including screening for conditions such as cancer and HIV and other offers recommended by the US Preventive Services Task Force, following a decision Thursday by US District Judge Reed O’Connor . Court of the Northern District of Texas. The White House is expected to appeal the decision, and industry observers say the decision could be the start of a lengthy legal battle.

The insurers do not plan to return to the drawing board anytime soon, but if the decision stands, it could affect further contracts.

Elevance Health, Kaiser Permanente and Blue Cross Blue Shield of Massachusetts said they will continue to pay for preventive benefits under the terms of their current contracts. The latter two also expressed concern about the decision and its potential impact on preventive consumer care.

“We know that these effective interventions prevent disease and save lives,” Kaiser Permanente said in a statement after the decision. “As we saw most recently during the pandemic, millions of Americans are facing economic inclusion, regardless of their health status or pre-existing medical conditions.”

UnitedHealth Group and Blue Cross Blue Shield of Michigan declined to comment on the ruling. Centene, Cigna, Humana, and Florida Blue did not respond to requests for comment.

Seth Chandler, a professor at the University of Houston Law Center, said preventive care coverage could be in jeopardy as health plans negotiate future contracts. Insurers may charge a co-payment for a preventive service or may cover only certain services in full.

“If Judge O’Connor’s decision stands, it will open preventive services to the same negotiation that other medical services are open to,” Chandler said.

The discrepancies can create problems for patients as they consider whether to get screened for cancer, diabetes and HIV, or drugs like statins, immunizations and PrEP.

“We are deeply concerned that this decision will cause consumer confusion about coverage and costs for important preventive services,” Blue Cross Blue Shield of Massachusetts said in a statement.

Some providers noted that this decision will particularly affect the most vulnerable segments of the country’s population.

“There’s a lot we don’t know about the impact of this decision,” Carolyn Witte, CEO of women’s healthcare provider Tia, said in a statement. “However, women in this country are already facing a ‘triple threat’ to their health — a growing lack of primary health care, a mental health epidemic and a reproductive health crisis. health has never been better.”

Dr. Viral Patel, CEO of primary care and mental health provider Radish Health, said the lack of coverage could deter patients in individual plans from seeking preventive care in the long term, leading to worse health outcomes and higher overall cost of care. . He noted that blood tests and procedures such as colonoscopy are common ways to detect serious illnesses early.

“It will be interesting to see how insurance companies try to promote cost-based care because obviously they are trying to save money,” Patel said. “Self-insured employers are trying to do the same. … Is it saving money in terms of health care today compared to results later?”

He said he believes employer-based health plans are more likely to see cost savings benefits from continuing to cover services.

Primary care provider Oak Street Health declined to comment on Thursday’s decision. VillageMD, One Medical, and Carbon Health, which also offer primary care, did not respond to requests for more information.