In 2022, a U.S. district court judge found a key part of the preventive service provision of the Patient Protection and Affordable Care Act unconstitutional. This ruling has important clinical, equity, and cost implications, as preventive care is important for individuals and overall public health. This week’s Fast Fact assesses the impact of imposing cost sharing on the services and prescription drug classes if the Braidwood Management Inc. v. Becerra court case is upheld.
Figure 2 Figure 1 Overall Use and Employer Savings Related to Select “A”- and “B”-Rated 2 Total Allowed Cost and Possible Cost Sharing of Select “A”- and “B”-Rated Services “ A” or “B” recommendation after 2010. In addition, there are currently two new recommendations and four Services Affected by the Judicial Ruling, 2019 Receiving Recommendation or Upgrade After March 2010 up Kirzing dateder, As recomm hley. end "KFF ation Health s in draft fo Trackin rm th g at wou Poll - Jul ld y 20 not b 19 e requ : The Future o ired to be cov f the ACA and ered withou Po t co ssible Ch st sharing ang . Moreov es to the er, Data and Methods Percentage of Employer Savings th e rulinCurr g maent y also affect a System, Preview o s many as 1 f Prio 7 rities Headin additional services g Into 2nd that rec Dem eived ocrati an c Debate." “A” or “B K ”FF, ratin 20 g 19. Available at prior to 2010, the Percentage of Total Allowed Cost Enrollee Out-of-Pocket If 20 Members Utilizing From 20 Percent ® recomme ht nd tpat s://www.k ions for wh ff.o ic rg h /h rece ealth ived -reform/p significant oll-fin up di dat ng/k es ff after -he alth the -si trackin gningg of -po th ll e- ju ACA ly-2019 . Over . all, about 30 services Total Cost We analyzed MarketScan pharmacy and medical claims data on a sample of 14.02 million members per User in 2019 Percent Coinsurance Service Coinsurance June 22, 2023, #474 may be affected by the ruling, though some are not identifiable via claims data, and others may be covered by continuously enrolled during 2019 in a non-capitated private health plan (including employer-sponsored Screening for Anxiety in Children and Adolescents (ages 8–18) $10 $2 Screening for Anxiety in Children and Adolescents (ages 8–18) 2% <0.01% <0.01% ot Norri her s, H. provisions C., Richard in theson ACA. , H. M ., Benoit, M.-A. C., Shrosbree, B., Smith, J. E., & Fendrick, A. M. (2021). and other commercial insurance). No further sample restrictions were applied. Therefore, the study cohort Utilization Impact of Cost-Sharing Elimination for Preventive Care Services: A Rapid Review. Medical Behavioral Counseling Interventions for Healthy Weight and Weight Behavin iorclud al Coed i unse ndi lingvi In du terals ventunder ions forage 6 Health 5, y W resid eigh in t a g nd in W all U.S. g eight eographic regions, and enrolled in a variety of plan $163 $33 0.04% <0.01% <0.01% This ru Ga lin iCare Res n g h in Pas impo regna earc ncyrtant h and clin Review ical, equ , 1-ity 23. , and cost implications, as preventive care is important for individuals Gain in Pregnancy types. Using relevant procedure codes and financial fields from claims, we derived mean per-member per- and public health. The U.S. Department of Health and Human Services has estimated that in 2020, 151.6 million year (PMPY) plan, member, and total cost measures for the “A”- and “B”-rated preventive services PreventivIm e Interposing ventions for PeriCo natal Dst epr eSharing ssion on Preventiv $454 e Servic $91es Preventive Interventions for Perinatal Depression 1% 0.09% 0.02% 3 Zip peo p, pl Rick e hady. acce "Mss to any Ameri free pr cans Are Lik eventive care ely unto der Sk th ip e Pr ACA event . Th ive Care is ACA if ACA Co provision verag is very e Falls T popular hr, ou favo gh." red Mornin by 62 g examined. We also captured the percentage of members with any utilization of each of the services, as well 4 percent of Americans. A recent review reported that removing cost sharing boosts the use of preventive services, Consult, 2023a. Available at https://pro.morningconsult.com/trend-setters/affordable-care-act-polling- Signi Pre-Expficantly osure Prophylaxis Im (PrEP)pact for Preves nt ioExpenditur n of HIV Infection* es for $13,733 Eligible $2Enro ,747 llees as the share of total costs represented by each service. Pre-Exposure Prophylaxis (PrEP) for Prevention of HIV Infection* 0.20% 0.38% 0.08% which helps reduce disparities and save lives (Norris et al. 2021). data. bS ut cre enDo ing foes r GestNo ationalt DiaSubsta betes+ ntially Reduce Ag $20 gregate Emplo $4 yer S creening for Gestational Diabetes+ 1% <0.01% <0.01% About EBRI: The Employee Benefit Research Institute is a private, nonpartisan, and nonprofit research institute Acc ordingly, we assessed the impact of imposing cost sharing of the services and prescription drug classes Zipp, Ricky. " A Federal Judge’s Ruling to Block ACA Requirement for No-Cost Preventive Care Is Unpopular." based in Washington, D.C., that focuses on health, savings, retirement, and economic security issues. EBRI does 5 ScreHeal ening for Hth Care epatitis B Virus In Spending fection in Adolescents: Impl and Adults ications of $25 Braidwood $5 Screening for Hepatitis B Virus Infection in Adolescents and Adults 1% <0.01% <0.01% rece iving an “A” or “B” recommendation from the USPSTF on enrollee and employer spending. If the judicial Morning Consult, 2023b. Available at https://pro.morningconsult.com/instant-intel/affordable-care-act- not lobby and does not take policy positions. The work of EBRI is made possible by funding from its members ruling stands, employers could impose cost sharing or remove coverage for the 15 services that did not have an preventive-care. and sponsors, which include a broad range of public and private organizations. For more information, visit Screening for Hepatitis C ViruManag s in Adolescentsement Inc. v. Bec and Adults $27 erra $5 Screening for Hepatitis C Virus in Adolescents and Adults 3% 0.01% <0.01% “A” or “B” rating before 2010. Of these, 10 of them were measurable in claims data. Furthermore, three of these www.ebri.org. Primary Care Interventions for Tobacco Use in Children and P services rimary Ca( re screen Interve in ntg ion fo s r fo gestatio r Tobaccnal o Usdi e abetes, HIV, an in Children and d intimate partner violence/elder abuse) might still require Endnotes $38 $8 0.20% <0.01% <0.01% Adolescents A cov doleerage wit scents hout cost sharing, as they are also recommended by the HRSA. This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), Screening for Human Immunodeficiency Virus Infection (for those S 1creening for Human Immunodeficiency Virus Infection (for those By Paul Fronstin, Ph.D., Employee Benefit Research Institute; M. Christopher Roebuck, Ph.D., Grandfathered health plans are not required to comply with this provision. According to KFF (2023), 13 percent of workers $38 $8 with the funding support of the following organizations: Aon, Blu1% e Cross Blue Shield <0.0 Associa 1% tion, ICUBA, JP <0.01% not at increased risk) for Pregnant Women+ not at increased risk) for Pregnant Women+ Our with em analy ploy ses m ent demon -based healt strate th ben wo impo efits we rtant re fin enrolle dings if t d in gra he ndfathe Braidwoo red pla d ru nslin . g is upheld and cost sharing is imposed: RxEconomics, LLC; and A. Mark Fendrick. M.D., University of Michigan Morgan Chase, Pfizer, PhRMA, and The Commonwealth Fund. Screening for Human Immunodeficiency Virus Infection (for those Screening for Human Immunodeficiency Virus Infection (for those 1) Enrollees using preventive services may face a substantial increase in their individual out-of-pocket spending, $34 $7 3% 0.01% <0.01% not at inn co rte a ats e in dc r re isa ks ) efd o rr iA sd k) o lfe os rc A ed no tsle a sn cd e n Ats d u altn sd ( a Ag de us lt s 1 5 (a –g 6e 4s )+ 15–64)+ 2 A few of these services might still require coverage without cost sharing as they are also preventive services for women and and 2) reintroduction of patient cost sharing will have a minimal impact on overall employer health care Notes: Notes: children recommended by the Health Resources and Services Administration (HRSA). spen di * U ng pd,a because te being drawhen fted spread across the entire pool of covered lives, the costs of covering select preventive * Wh Updaen t te behe P ing dra atient fted Protection and Affordable Care Act (ACA) passed in 2010, it included provisions requiring that References 1 + HRSA-Supported Women's Preventive Services. + HRSA-Supported Women's Preventive Services. services are very low. most employers and health plans cover certain preventive services in full. The preventive services come from 3 See “Access to Preventive Services” (2022). recommendations by the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on “Access to Preventive Services without Cost-sharing: Evidence from the Affordable Care Act” (Issue Brief No. Im Im 4 Imm pact on pact on unizatioEmployer Spending Workers and Their Dependents n Practices (ACIP), the H ealth Resou rces and Services Administration’s (HRSA’s) Bright Futures See Kirzinger (2019). HP-2022-01). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health Discussi on Project, and the HRSA-sponsored Women’s Prevention Services Initiative (WPSI). The combined list of about 90 and Human Services. January 2022. 5 If emplo If th pr event e cou iv yers e rt dec serv were isio ices allo n in is u clud wpheld ed es and , bu and cho t is th se not lim e co to impo verag ited se 20 e ma to, screen p nd erce ate in nt fogs cost r th fo e pr r cancer and sha event ring iv on e care all oth th e s e r h ervices re “A ealth co ”- andceiv nd “B itio ”in -rated serv g ns, an vacc “A” in and ic ation es and s, We did not examine 10 services because they were either not measurable from claims data or applied to individuals ages 65 and o “B” me and Emplo di b rat cation lirth der, yers m in cont g who aft s that ay co are ge er March rol.are m Pnt lan ner inal ue to p e spon 20 asu ly10 no rable i sors t c is roovere in vide th hav valid n claims d e bee d b at e y empl se se ed, n pr e ata for rv mplo oyme ohib ices at ited yers an nt in -ba divid no fro sed heal cost m d uals u health impo to th mem nder age pla sing plans cou ns bers fo any . 65, fold r at l rm of c em impo pl eas oy se ost t a fe er spen some for sharin w rea di gng wo son m of (i.es. Emp ., ul ded cost d uctible, fall lo sharin ye by rs g Fronstin, Paul,"Can 'Consumerism' Slow the Rate of Health Benefit Cost Increases?," EBRI Issue Brief no.247 0. fo ma 48 r th y no percent. ese t want prevent to Similarly cut ive b service enefit , in aggr s d s. Th uregate, in ey co g a tim ul “A d e when ”also - and complet “ u Bnemplo ”-raely ted yment dr services a op coverage fo is low, ccoun and t fo r th recruit r on ese ly services. me 2.4 percent nt andFo retentio r example, of ton tal sp of wo if enrdi kers ng. copayments, or coinsurance) on participants receiving these services. However, a recent federal judicial opinion in (Employee Benefit Research Institute, July 2002). 6 Now that PrEP is available as a generic, user out-of-pocket costs will be somewhat less. em is o Texas m pl f co oyncern ers ay p we ut . E re cov mplo to impo erage yers may co swith e 20 p nerce o nt out in nt -ue of coinsuran -to po o cket co ffer cov ce, sts of th erage fo e cost o some r th f b of ese ehavioral co thes services in e prevent un iv fu seling e service ll if th iney b terven s in elie jeo tive t ons fo pard hat y. r h in ealthy centivizing th If emplo weigh eir ut an se redu ye d rs impo weigh ces agg t g sed 2 ain regate 0 in preg pe h rcent co ealth sp nancy st end csh ould iaring ng in am o tou he l n t nt ho ong ts o at leas e 10 term. And services t $33 th pe th ere is pr r p at eith erson er eced on on laverage, e y nt rece for co ived t th vering e c he ost “A th of ”ese / “pr B servic eventive ” rating es 7 Fronstin, Paul, and A. Mark Fendrick,, "Employer Uptake of Pre-Deductible Coverage for Preventive Services in According to a recent consumer survey, 37 percent of adults said they “definitely” or “probably” expect to delay or avoid after March in with terven out co tiost s ns for p 201 harin 0 or erinatal d g were in the a upg epression bsen rade ce of d to c th “ ou A e ACA ld ”/“ amou B” after ma ntnd to at leas 20 ate. Wh 10 (Fig t $ en h ur 91 e ealth r 1) pe, emplo r peimbur erson yer on sem spen ave ent rage, diarr ng would ang and em th fall ents ( e cost o by HRA only f HIV s) were 0.10 On September 7, 2022, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas found a HSA-Eligible Health Plans," EBRI Issue Brief, no. 542 (Employee Benefit Research Institute, October heath care due to potential costs following the ruling, and at least 2 in 5 adults said that they are not willing to pay for 6 in percent. key PrEP tro p du art o cou ced i Pre ld f the prev re - n the early each $ xposu 2, entiv re p 747 2 rop 000s, e service pe hy r u laxis so ser. me s (PrE pr Th emp ov e cost o P isio lo ) fo yers p n r p uncon f th reven ro ese vid stit ser tied f on utvi io o irst ces nal f HIV in - cou . Specifically, dollar co ldf be sub ection verag and ject to th e fo e decisio pr r p deductib event reven iv n e in tiv inles as e services Braidwo terven well. tio od ns (Fro fonsti r n preventive services that are currently fully covered by the ACA. See Zipp (2023a)and Zipp (2023b). 2021). 2002) Man perinag atal dep . Co eme mparable g ntress Inc. v. B ion acc enero ece ou rr nt us a fo refers to cov r th erage was imple e overwhelming the part of th men ma e A ted CA jority when th o at f h requ the e potenti alth ires savin cov al savin erage gs acc with gs. ount ou (HSA) t cost s -eligi harin blg e healt of h plans W were ere e inmplo troduyers to ced (Fro not nsti cover th n, Sepu ese lveda, an services d Roeb , the o uck ut- of 2013 -po)cket co . Similarl st p y, er u recent rese ser couldarch h easily as fou exceed t nd th he at when total allowed the IRS pr 8 eventive services rated “A” or “B” by the USPSTF. The judge ruled that these recommendations are Also see “HSA-Eligible Health Plans Embrace Changes” (2021) and Internal Revenue Service (2019). Fronstin, P., Sepulveda, M. J., & Roebuck, M. C. (2013, June). Consumer-Directed Health Plans Reduce The allowed am In un o con ou urnt analy stitu s sho empl tional b si wn oy s oers and in f P eca Fi rEP gu use t h re dr ealth p ugs, we fo he 1, b USPS eca lans t use TF un some o — d that t cov a gr er certain p enro ou he co llees p the st wou Ag of these dr reven ency ld no l tivfo e ser onger ug r Healthcar s vi on ces ben a p oefit fro ut er e R side -patien ese m plan of ar t b HSA ch an asis is relatively -neg -eligi d Quality otiate ble health d h rates as been h p .ig lan h at Long-Term Use Of Outpatient Physician Visits And Prescription Drugs. Health Affairs, 32(6), 1126- ded auth $13, uctib or 733 ized b les, abo per y the U.S year. utHowever three . Co -qua ngress , rters o because so tof th con em ve few enro ne sin chose to ce 19 llees do98 s ut o, ilize PrE — often is an witho in P medicatio deut pen cost densharin t, ns vo (abo lun g teer pan ut (Fro 0.nsti 2 per el o n cent o and f n Fen ation f all dr al ex ick members), perts ### 1134. 8 2021) th If en e to ro tal cost .llees had of th toese pay out drugs of accoun pocket, u t for o se o nlf h y 0. ealth care service 38 percent of tos wo tal sp ul end d lik ing. ely Th fall, us, i even f em fo plr servi oyers impo ces th sed 2 at wer 0 e not in prevention and evidence-based medicine whose members are not appointed by the president and confirmed by 7 con percent the Senate sidered cost , t costly hereb sharin , y especia g vi on p olating th ati lly ents fo am e on Ar P pp g lo rEP oint wer me dr -in ug nt come ind s, employer sp s Clauseiv . iduals end who ing wou may ld fin fall d any by cost a b less than arrier one-to tenth care. of 1 percent. “HSA-Eligible Health Plans Embrace Changes to Better Serve Americans With Chronic Health Conditions.” E Fu mplo rtherm yers ore, n couow ld realize mo that PrEP is av re meailable as a g asurable cost eneric, reduction ems if ploy th er sav e addi intio gs n of from impo cost sharin singg cost s reduced u harinse of g will b these e AHIP, 2021. Available at https://ahiporg-production.s3.amazonaws.com/documents/202109- pr somewhat eventive services less. But. Ho as me we nver tio, i ned mpo above, sing cost the cost t sharin o g for enrollees impac preventive service ted by th s wo e plul an d d reverse a gro esign change cou wingld movem be ent On March 30, 2023, the judge ruled on the remedy. The judicial opinion impacts: AHIP_HDHP-Survey.pdf. sub am on stantial g empl . oyers in recent years to expand coverage of clinically effective care without deductibles or copays (Fro nstin and Fendrick 2021). • Services receiving an “A” or “B” recommendation after March 2010. Internal Revenue Service, Notice 2019-45, Additional Preventive Care Benefits Permitted to be Provided by a Taken together, as enrollees reduce use of “A”- and “B”-rated preventive services, other health care costs may • Services upgraded to an “A” or “B” recommendation after 2010. High Deductible Health Plan Under § 223 (2019). Available at https://www.irs.gov/pub/irs-drop/n-19- increase. For instance, colorectal cancer screenings are one of the services that have seen a significant update to Conclusion • Services receiving an “A” or “B” recommendation in the future. 45.pdf. the original USPSTF recommendation. While employers may realize marginal short-term savings from subjecting colo rectal cancer screening to cost sharing, their costs may be higher in the future if enrollees avoid needed health If the Braidwood decision were to be upheld and employers reimposed cost sharing on preventive services that are The list of approximately 50 USPSTF “A”- and “B”-rated services and how the judicial opinion affects them can KFF, "Preventive Services Covered by Private Health Plans under the Affordable Care Act," KFF, 2023. care now, as some enrollees will not prevent the onset of cancer. Employee productivity may also be affected if currently free to enrollees, individuals using those services could face a significant increase in out-of-pocket be found at https://vbidcenter.org/wp-content/uploads/2023/04/Braidwood-USPSTF-Table.pdf. In summary, if Available at https://www.kff.org/womens-health-policy/fact-sheet/preventive-services-covered-by- e mployees are worried about being unable to get preventive care or the expense of getting that care. spending. Although this potentially onerous financial burden could deter care on the individual beneficiary level the ruling is upheld, there are five services that would no longer require coverage without cost sharing that private-health-plans. and likely worsen health inequities, employers would see little impact on their overall spending. received an “A” or “B” recommendation after March 2010, and there are 10 services that were upgraded to an EBRI on Twitter @EBRI or twitter.com/EBRI LinkedIn: linkedin.com/company/employee-benefit-research-institute E E E E EBRI BRI BRI BRI BRI o o o o on n n n n T T T T Tw w w w wi i i i it t t t tt t t t ter: er: er: er: er: @ @ @ @ @E E E E EBRI BRI BRI BRI BRI o o o o or r r r r t t t t tw w w w wi i i i it t t t tt t t t ter.c er.c er.c er.c er.co o o o om m m m m/ / / / /E E E E EBRI BRI BRI BRI BRI L L L L Li i i i in n n n nk k k k ke e e e ed d d d dI I I I In n n n n: : : : : l l l l li i i i in n n n nk k k k ke e e e ed d d d di i i i in n n n n.c .c .c .c .co o o o om/ m/ m/ m/ m/co co co co comp mp mp mp mpa a a a an n n n ny y y y y/ / / / /emp emp emp emp empl l l l lo o o o oy y y y ye e e e ee e e e e- - - - -b b b b ben en en en ene e e e efi fi fi fi fit t t t t- - - - -re re re re res s s s search earch earch earch earch- - - - -i i i i in n n n ns s s s st t t t ti i i i it t t t tu u u u ut t t t te e e e e © 2023, Employee Benefit Research Institute, 901 D St. SW, Suite 802, Washington, DC 20024, 202/659-0670 | ebri.org 4 3 2 5 6