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Judge Deals Blow to Preventative Care Coverage under ACA

A recent decision by a federal judge in Texas to issue an injunction on a pivotal part of the Affordable Care Act requiring insurers to offer certain types of free preventative care, has raised concerns that some health plans will stop paying for these services.

However, since most employer-sponsored plans are on annual contracts, the decision is unlikely to affect policies in 2023, but beyond that, it’s uncertain how things will play out. The Biden administration has appealed and called for a hold on the ruling until the decision is settled by higher courts.

What’s at stake

If the ruling by Judge Reed O’Connor of the Federal District Court for the Northern District of Texas sticks, it would roll back the health insurance market to the days prior to the ACA when health insurers decided which preventative care services they would cover with no cost-sharing.

The ACA changed all that, requiring insurers to pay for preventative services, such as: 

  • Cancer screenings, like breast cancer screenings and colonoscopies 
  • HIV screenings
  • Diabetes screenings
  • Heart disease screenings
  • Pap smears
  • Depression screenings
  • Statins
  • Immunizations and PrEP for HIV and HPV.

Judge O’Connor in 2018 issued a decision striking down the entire ACA, which was later reversed by the U.S. Supreme Court. 

The most recent ruling is really two decisions: 

  • That a panel of volunteer experts that issues binding recommendations on what preventative care must be covered under the ACA violated the Constitution because its members are not appointed by the president or confirmed by the Senate.
  • That the ACA requirement that insurers must cover PrEP and HPV vaccines, as well as certain HIV/Aids-prevention drugs, violates the religious beliefs of Christians, which in turn violates the Religious Restoration Freedom Act.

The fallout

The consequences of the ruling are unlikely to be felt immediately, particularly for group health plans, the annual contracts of which include coverage for preventative services. 

Matt Eyles, president and CEO of the trade association America’s Health Insurance Plans, issued a statement saying that:

“As we review the decision and its potential impact with regard to the preventive services recommended by the United States Preventive Services Task Force, we want to be clear: Americans should have peace of mind there will be no immediate disruption in care or coverage. We fully expect that this matter will continue on appeal, and we await the federal government’s next steps in the litigation, as well as any guidance from relevant federal agencies.”

That said, if the Biden administration fails in convincing higher courts to put a hold on the injunction while the appeal of the decision plays out, changes could come over time. 

In this continuing tight job market, many employers would likely be reluctant to roll back these preventative services in their health plans. And if insurers plan to make changes to their plans’ benefits, they are required to give advance notice. 

Other pundits have said that the preventative care provisions of the ACA have become so ingrained in the health care system that employers and insurers would have a hard time rolling these benefits back, and many may not consider it.

Let’s not forget, most important that preventative care can save employees, insurers, and employers potentially millions in savings before more serious complications occur.

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