Tom and Mary Jo York are a health-conscious couple who undergo annual physicals and regular colorectal cancer screenings. Mary Jo, whose mother and aunt had breast cancer, also has regular mammograms.
The Yorkes, who live in New Berlin, Wisconsin, are members of the Corus Community Health Plan. It, like most health insurance in the country, is required by the Affordable Care Act to pay for these preventive services and over 100 other services. Claim deductibles or out-of-pocket costs.
Thom Yorke, 57, said he appreciates the legal obligations as the deductible on his plan until this year was $5,000. That means, without ACA provisions, he and his wife would have had to pay full price for these services until the deductible was met: “A colonoscopy could cost him $4,000.” there is potential,” he said. “I can’t say I skipped it, but I would have had to think hard.”
Currently, health insurance and self-insured employers (companies that pay for their workers’ or dependents’ medical care) may consider imposing a cost share for preventive services on their subscribers or workers. . That’s because a September 7 federal judge’s ruling led conservative groups to argue that the ACA’s order that medical insurance pays for the full cost of preventive services (often called first dollar coverage) is unconstitutional. for ruling in a Texas lawsuit filed by
U.S. District Judge Reed O’Connor agreed with them. He argued that members of the U.S. Preventive Services Task Force, one of his three groups making reparation recommendations, were not nominated by the President or approved by the Senate, and therefore legal under the Constitution. was not appointed to
If the obligation to cover preventive services were to be partially rescinded, the result could be a confusing patchwork of health insurance benefit designs offered in different industries and in different parts of the country. Patients with medical conditions or at high risk for such conditions may struggle to find plans that fully cover prevention and screening services.
O’Connor also alleged that requiring plaintiffs to pay for HIV prophylaxis violated the Religious Freedom Restoration Act of 1993. He is also considering revoking his $1 coverage mandate for contraceptives, which plaintiffs challenged under the law. We have deferred judgment and legal remedies pending receipt of additional summaries. court.
If O’Connor ordered the immediate termination of the free compensation obligation for services approved by the Preventive Services Task Force, nearly half of the preventive services recommended under the ACA would be at risk. These include screening tests for cancer, diabetes, depression, and sexually transmitted diseases.
Many health insurance and self-insured employers may respond by imposing deductibles or copays for some or all of the services recommended by the Task Force.
“Bigger employers will value what covers the first dollar and what doesn’t,” says the National Alliance of Health Plans, a nonprofit organization of employers and unions working together to bring prices down. said Michael Thompson, CEO of Healthcare Purchaser Coalitions. He believes employers with high employee turnover and health insurance companies are most likely to add cost burdens.
Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, said it could destabilize the health insurance market.
Insurers will design benefits for preventive services to attract the healthiest people so they can lower premiums, she predicted, and pay for the sick and the elderly with less coverage and higher out-of-pocket costs. “It reintroduces the mess the ACA was designed to fix,” she said. “It becomes a race to the bottom.”
The services most likely to qualify for cost sharing are HIV prevention and contraception, said Dr. Jeff Levin Schaerts, population health leader at WTW (formerly Willis Towers Watson), who advises employers on health plans. I’m here.
Research shows that eliminating cost sharing increases access to preventive services and saves lives. After the ACA required Medicare to cover screening for colorectal cancer without cost-sharing, early-stage colorectal cancer diagnoses increased by 8% annually and life expectancy improved for thousands of seniors. , according to a 2017 study published in the journal Health Affairs.
Many Americans are on highly deductible plans, so adding cost sharing can add up to hundreds or thousands of dollars in out-of-pocket costs for patients. According to eHealth, a private online insurance broker, the average annual deductible for the individual insurance market in 2020 was $4,364 for single coverage and $8,439 for family coverage. According to KFF, the employer plan was $1,945 for an individual and $3,722 for a family.
Because O’Connor upheld the constitutional authority of two other federal agencies to recommend preventive services and immunizations for women and children, the first dollar of compensation for those services is at risk. It seems not.
Health insurance executives face tough decisions when courts vacate orders from the Preventive Services Task Force’s recommendations. Mark Rakowski, president of the nonprofit Chorus Community Health Plans, is a strong believer in the health value of preventive services, and waiving deductibles and copays makes it affordable for registrants. said that he wishes to
But if the mandate is partially repealed, he expects competitors to set deductibles and pay copays for preventative services to reduce premiums by about 2%. He said he would then have to do the same to keep his plans competitive in his ACA market in Wisconsin. “I don’t want to admit that I have to strongly consider following this,” Rakowski said, adding that it may offer other plans with free preventive insurance and higher premiums. .
The ACA’s applicable rules for preventive services apply to private plans in the individual and group market, which serves more than 150 million Americans. According to his KFF survey in 2019, this is a provision of the law supported by 62% of Americans.
Spending on ACA-mandated preventive services is relatively small, but not significant. According to the Health Care Cost Institute, a nonprofit research group, this equates to 2% to 3.5% of total annual health insurance spending for private employers, or about $100 to $200 per person.
Several large insurers and health insurance industry groups did not respond to requests for comment or declined to comment on what payers will do if a court terminates an order for preventive services.
Experts fear that sharing the cost of preventive services will undermine efforts to reduce health disparities.
University Director Dr. A. Mark Fendrick said: Ph.D., Michigan Center for Value-Based Insurance Design, who helped draft the ACA’s Preventive Services Coverage Section.
One service of particular concern is HIV pre-exposure prophylaxis, or PrEP. This is a highly effective drug regimen that prevents high-risk people from contracting HIV. Plaintiffs in a Texas lawsuit argued that because they had to pay for PrEP, they were compelled to subsidize “homosexual acts” with religious objections.
Starting in 2020, health insurance will be mandatory to fully cover PrEP drugs, which cost thousands of dollars a year, and associated lab tests and doctor visits. 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. There are also many low-income earners. Before the PrEP coverage rule went into effect, only about 10% of eligible black and Hispanic people had started PrEP treatment because of the high cost.
O’Connor cites evidence that PrEP drugs reduce sexually transmitted HIV transmission by 99% and injecting drug transmission by 74%, yet the government should not mandate free PrEP compensation. He claimed that he had failed to show compelling government interest in
“We are working to make PrEP easier, but there are already many barriers,” said Karl Schmidt, executive director of the Institute for HIV+Hepatitis Policy. When it’s gone, people won’t pick up drugs, which will be very damaging to our efforts to end HIV and hepatitis.”
Robert Yorke, an LGBT activist from Arlington, Virginia who is unaffiliated with Thom Yorke, has been taking Desicovy, a brand-name PrEP drug, for about six years. He said that under his employer’s health insurance scheme he would have to pay a share of the medication and related tests every three months, which would force a change in his personal spending. rice field. The retail price of the drug alone is about $2,000 a month.
But York, 54, stressed that reestablishing PrEP cost sharing would have an even greater impact on people from low-income and marginalized groups.
“We have been working hard with the community to get PrEP into the hands of those in need,” he said. “Why would anyone want this?”
This article is reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. An editorially independent news service, Kaiser Health News is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization independent of Kaiser Permanente.