The Affordable Care Act’s Impact on Prevention: Examining Access to Affordable Preventive Health Services
By: Nancy K. Ryan, Esq.
One promising aspect of the Patient Protection and Affordable Care Act (ACA) is the opportunity for increased access to preventive health services. Since 2010, most health plans have been required to cover a range of services, such as annual wellness visits and cancer screenings, without cost-sharing by plan members. For consumers, particularly those with limited incomes, this mandate reduces financial obstacles to better health. Unfortunately, implementation by health plans has been uneven, leaving members with uncovered charges. More oversight and broader consumer engagement is needed for the preventive services mandate to have its intended broad effect.
Even with health insurance, many consumers face unaffordable health care costs. From $25 copays for physician visits to 20 percent coinsurance for medical procedures, having health insurance does not insulate people from medical bills. As a result, many low-income consumers have avoided necessary care. Ideally, ready access to preventive services leads to better health and reduced medical costs over time.
Through the ACA, Congress sought to eliminate the financial disincentives to obtaining preventive health care. The ACA mandates that group health plans and health insurance issuers cover a range of preventive health services without cost-sharing. This mandate applies to the majority of health plans, including employer-sponsored plans, student health insurance, and private non-group insurance. Most privately insured residents of Massachusetts have health plans subject to the preventive services mandate. The preventive services mandate represents one of the major benefits available to Massachusetts residents under federal reform.
Neither the text of the ACA nor the law’s implementing regulations specifies the preventive services that health plans must cover without cost-sharing. Instead, the law and regulations refer to guidelines and recommendations issued by the Centers for Disease Control and Prevention, the Health Resources Services Administration, and the United States Preventive Services Task Force. By incorporating these guidelines and recommendations, the ACA allows for flexibility in determining services subject to the mandate over time. This flexibility will be important as new standards and technologies develop in preventive medicine.
For adults, preventive services that must be covered without cost-sharing include screening for colorectal, breast and cervical cancers, blood tests for cholesterol and sexually transmitted infections, and counseling for certain conditions. Preventive services that must be provided for children at no cost include regular immunizations, certain blood tests, and vision and hearing exams. Additional services that must be covered for women include an annual physical, the full range of FDA-approved contraceptive methods, and lactation equipment and supplies.
Consistent with the law, implementation of the preventive services mandate began shortly after the ACA’s passage, with plan years beginning on or after September 23, 2010. The mandate relating to coverage of preventive services for women was delayed until August 1, 2012.
Despite the relatively swift implementation of the mandate, putting the preventive services benefit fully into effect has been fraught with difficulty. This is due in part to the lack of specificity in the statute and regulations. Health care providers and health plans communicate through a complex system of medical billing codes. The recommendations issued by the Preventive Services Task Force and other responsible agencies list services generally, without diagnosis or procedure codes. This disconnect between the recommendations and the way that services are identified and authorized by health plans has led to differential treatment of consumers depending on the plan.
Further, the mandate allows for the use of “reasonable medical management” by health plans. This means that health plans may determine coverage limitations and cost-saving techniques where the guidelines do not specify the frequency, method, or setting for a service. This medical management “loophole” has also resulted in wide variation among health plans.
The ACA’s promise of cost-free contraception demonstrates the inconsistent application of the preventive services benefit. Upon the benefit’s initial implementation, many health plans offered only oral contraceptives at no cost, while imposing cost-sharing for other methods. Further, many plans covered only generic contraceptives at no cost. Due to this confusion, the Employee Benefits Security Administration (EBSA) issued guidance in February 2013. EBSA clarified that a health plan must cover the full range of FDA-approved contraceptive methods. EBSA further clarified that health plans may limit cost-free coverage to generic alternatives but only if medically appropriate for the patient.
EBSA has issued extensive guidance on many aspects of the preventive services benefit. This guidance has offered greater clarity to health plan members seeking preventive health services. Nonetheless, health plans may still determine coverage limitations where federal law does not specify the frequency or method of treatment. Thus, with respect to cancer prevention, patients face confusion about coverage for colorectal, breast and cervical cancer screenings. For example, health plans differ as to whether future colorectal cancer screening must be cost-share free for a patient that had polyps removed during a prior colonoscopy. Also unresolved is the question of whether more frequent screenings due to higher risk of cancer (such as indicated by colon polyps) must be covered without cost-sharing.
Impact on Prevention
The interim final rule, released in July 2010, underscores three main factors that contribute to underutilization of preventive health services and the need for federal action: (1) health insurers have no financial incentive to cover preventive services as the cost-saving benefits are long-term and lost entirely when members switch health plans; (2) individuals do not see an immediate benefit from preventive services and thus do not obtain them; and (3) the benefits of preventive care are most evident population-wide, requiring centralized action to provide incentives on a broad scale. The ACA seeks to provide a clear incentive to health plan members to obtain preventive care. However, the inconsistent implementation of the mandate has eroded this consumer incentive.
Further federal guidance and enhanced consumer engagement are needed for the preventive services mandate to have its intended broad effect. To increase utilization of preventive health care, thereby improving population health and reducing long-term health system costs, health plans and insurers must implement the mandate more consistently. Federal guidance since 2010 has not led to uniform implementation across health plans. This lack of uniformity has undermined consumer confidence in the ACA’s preventive services benefit, likely hindering the intended impact of this important provision. And yet, consumers can assert their own rights in enforcing the preventive services mandate. When faced with unanticipated costs for preventive services, members should challenge health plan determinations. The health plan appeal process plays an important role in protecting consumers’ rights and can lead to meaningful change within health plan policies.
It is too early to tell whether the ACA’s preventive services mandate will meet its goal of improving overall health and reducing health system costs. The implementation process has been uneven and, in many ways, marked by confusion for plans and consumers alike. More federal guidance and oversight and broader consumer engagement are needed for the preventive services mandate to have its full beneficial effect.
 Patient Protection and Affordable Care Act (ACA), Pub. L. 111-148, § 2713(a), 124 Stat. 119 (2010).
 Only “grandfathered” plans are exempt from the preventive services mandate, To qualify as “grandfathered” a plan had to be in effect on March 23, 2010 and have made no significant changes to coverage since that time.
 Chapter 58 of the Acts of 2006 substantially reformed Massachusetts’ health insurance system and served in part as the template for federal reforms under the ACA.
 United States Preventive Services Task Force’s A and B Recommendations, available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm
 American Academy of Pediatrics’ Recommendations for Pediatric Preventive Care, available at http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf
 75 Fed. Reg. at 41726 (July 19, 2010).
 76 Fed. Reg. at 46621 (August 1, 2011).
 United States Department of Labor. Employee Benefits Security Administration’s Frequently Asked Questions (FAQ) about Affordable Care Act Implementation Part XII, released February 20, 2013, available at http://www.dol.gov/ebsa/faqs/faq-aca12.html.
 For a detailed analysis of health plans’ implementation of the colorectal cancer screening benefit, see Coverage of Colonoscopies under the Affordable Care Act’s Prevention Benefit, Karen Pollitz, MPP, Kaiser Family Foundation, et al. (September 2012).