A court injunction could encourage competing health plans to roll back copays for services.

Tom and Mary Jo York are a health-conscious couple who go for annual physicals and regular colorectal cancer screening tests. Mary Jo, whose mother and aunt had breast cancer, also gets regular mammography tests.

York, who lives in New Berlin, Wisconsin, is enrolled in Coors Community Health Plans, which, like most health plans in the country, are required by the Affordable Care Act to pay for these preventive services, and 100 More than others, without. Charging deductibles or copays.

Tom York, 57, said he appreciates the law’s mandate because until this year the deductible on his plan was $5,000, meaning that without the ACA provision, he and his wife would have paid the full cost of those services. Pay until the deduction is met. “A colonoscopy can cost $4,000,” he said. “I can’t say I would have given it up, but I’d have to think hard about it.”

Now health plans and self-insured employers — those who pay for workers’ and dependents’ medical expenses themselves — may consider imposing cost-sharing on their members and workers for preventive services. That’s because of a federal judge’s Sept. 7 ruling in a Texas lawsuit filed by conservative groups that claims the ACA’s mandate that health plans pay the full cost of preventive services, which are often Called first dollar coverage, is unconstitutional.

U.S. District Judge Reid O’Connor agreed. He ruled that members of one of the three groups making the coverage recommendations, the U.S. Preventive Services Task Force, were not legally appointed under the Constitution because they were not appointed by the president and were not appointed by the Senate. was not confirmed.

If the preventive services coverage mandate is partially eliminated, the result could be a confusing patchwork of health plan benefit designs offered in different industries and in different parts of the country. Patients with serious medical conditions or at high risk for such conditions may find it difficult to find a plan that fully covers preventive and screening services.

O’Connor also said that requiring plaintiffs to pay for HIV prevention drugs violates the Religious Freedom Restoration Act of 1993. He’s also considering eliminating the first-dollar coverage mandate for contraceptives, which plaintiffs also challenged under the law. O’Connor adjourned the ruling and legal remedies until he takes additional briefs from the parties for the trial on September 16. No matter what the judge does, the case will likely be appealed by the federal government and could go all the way to the Supreme. Court

If O’Connor orders an immediate end to the no-cost coverage mandate for services that received approval from 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 infections.

Many health plans and self-insured employers will likely respond by imposing deductibles and copays for some or all of the services recommended by the task force.

“Large employers will evaluate first dollar what they cover and what they don’t cover,” said Michael Thompson, CEO of the National Alliance of Healthcare Purchaser Coalitions, an association of employer and union health plans. A non-profit group that works together to help lower costs. . He thinks employers with high employee turnover and health insurance companies are more likely to add cost-sharing.

That could destabilize health insurance markets, said Kathryn Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation.

Insurers will design health care benefits to attract the healthiest people so they can lower their premiums, he predicted, for sicker and older people with skimpier coverage and higher out-of-pocket costs. are “It reproduces the chaos that the ACA was designed to fix,” he said. “It becomes a race to the bottom.”

WTW (formerly Willis Towers Watson) population health leader Dr. Jeff Leon-Shears said the services most likely to be targeted for cost-sharing are HIV prevention and contraception.

Studies show that eliminating cost-sharing increases the use of preventive services and saves lives. After the ACA required that Medicare cover colorectal cancer screening without cost-sharing, early-stage colorectal cancer diagnoses increased by 8% each year, improving the life expectancy of thousands of seniors, the journal Health Affairs reported. According to a 2017 study published in

Adding cost-sharing can mean hundreds or thousands of dollars in out-of-pocket costs for patients because many Americans are enrolled in high-deductible plans. In 2020, the average annual deductible in the individual insurance market was $4,364 for single coverage and $8,439 for family coverage, according to eHealth, a private, online insurance broker. For employer plans, it was $1,945 for an individual and $3,722 for families, according to KFF.

O’Connor upheld the constitutional authority of two other federal agencies to recommend preventive services for women and children and immunizations, so first-dollar coverage for those services appears not to be in jeopardy.

If the courts strike down the mandate of the Preventive Services Task Force’s recommendations, health plan executives will face a tough decision. Mark Rakowski, president of the nonprofit Course Community Health Plans, said he strongly believes in the health value of preventive services and would like to make them more affordable for enrollees by eliminating deductibles and copays.

But if the mandate is partially eliminated, he expects competitors to institute deductibles and copays for preventive services to help lower their premiums by about 2%. Then, he said, he would be forced to do so to keep his plans competitive in Wisconsin’s ACA marketplace. “I hate to admit that we’re going to have to seriously consider the following suit,” Rakowski said, adding that he could offer other plans with no cost-savings coverage and higher premiums. .

The ACA’s coverage rule for preventive services applies to private plans in the individual and group markets, which cover more than 150 million Americans. According to a 2019 KFF poll, this is a popular provision of the law, with 62% of Americans favoring it.

Spending on preventive services mandated by the ACA is relatively low but not uncommon. That’s 2% to 3.5% of the total annual costs of private employer health plans, or about $100 to $200 per person, according to the Healthcare Cost Institute, a nonprofit research group.

Several major commercial insurers and health insurance trade groups did not respond to requests for comment or declined to comment on what payers would do if courts struck down the preventive services mandate.

Experts worry that cost-sharing for preventive services will undermine growing efforts to reduce health disparities.

“If these decisions about cost sharing are left up to individual plans and employers, removing cost sharing will disproportionately harm black and brown communities that benefit,” said University Director Dr. A. Mark Fendrick. ” Michigan Center for Value-Based Insurance Design, which helped draft the preventive services coverage section of the ACA;

One service of particular concern is pre-exposure prophylaxis for HIV, or PrEP, a highly effective drug regimen that prevents high-risk people from acquiring HIV. Plaintiffs in the Texas lawsuit claimed that paying for PrEP forces them to subsidize “homosexual behavior” to which they have religious objections.

Starting in 2020, health plans are required to fully cover PrEP medication and related lab tests and doctor visits that could otherwise cost thousands of dollars a year. According to the Centers for Disease Control and Prevention, of the 1.1 million people who could benefit from PrEP, 44% are black and 25% are Hispanic. Many are also low-income. Before the PrEP coverage rule went into effect, only 10% of eligible blacks and Hispanics started PrEP treatment because of the high cost.

O’Connor, despite citing evidence that PrEP drugs reduce the spread of HIV through sex by 99% and injection drug use by 74%, said the government would mandate no-cost coverage of PrEP. It did not show a compelling government interest in the declaration.

“We’re trying to make it easier to get PrEP, and there are already a lot of barriers,” said Carl Schmid, executive director of the HIV + Hepatitis Policy Institute. “If the first dollar of coverage is lost, people will not pick up drugs. This will be extremely detrimental to our efforts to end HIV and hepatitis.

One photo shows Robert Yorke standing in front of a rainbow background.
Robert York, an LGBT activist who lives in Arlington, Virginia, has taken PrEP, a treatment designed to prevent HIV, for about six years.(John Jack Gallagher)

Robert York, an LGBT activist who lives in Arlington, Virginia, who is not related to Tom York, has been taking Descovi, the brand-name PrEP drug, for about six years. He said paying cost-sharing for drugs and related tests every three months under his employer’s health plan would force a shift in his personal expenses. The retail price of the drug alone is $2,000 per month.

But York, who is 54, stressed that reinstating cost-sharing for PrEP would affect people in low-income and disadvantaged groups even more.

“We’re working very hard with the community to get PrEP into the hands of people who need it,” he said. “Why is someone targeting him?”

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