Health plans could soon reduce coverage for preventive care. Here’s what to know

After a federal judge in Texas struck down a key provision of the Affordable Care Act last month, some health insurance plans may soon scale back their preventive care coverage, experts say.

U.S. District Judge Reed O’Connor ruled in late March that one of the three panels of health-care experts that advise the government on what preventive services insurers should cover — the U.S. Preventive Services Task Force — did not have the authority to issue such guidance.

As a result of the ruling, health plans may drop their no-cost coverage based on recommendations from that panel, including certain cancer screenings and medications that protect against H.I.V.

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“This decision is a really big deal,” said Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation. “If left standing, it will drive up costs and worsen outcomes for adults, children and infants across the country.”

The Biden administration has already appealed O’Connor’s decision, and it’s possible the case could reach the Supreme Court.

Here’s what you should know.

The ACA’s preventive services mandate covered most people who have private health insurance, either through their employer or from the public exchange, Donovan said.

Around 100 million people with private insurance got preventive care required under the ACA in 2018, one estimate found, making it the provision with the widest reach. Insurers generally must not impose copays or deductibles on the recommended preventive care.

The ruling doesn’t appear to have a direct impact on those covered by Medicaid or Medicare, experts say.

The decision out of Texas means insurers are no longer required to provide free coverage based on recommendations made from the U.S. Preventive Services Task Force since 2010.

However, the other two panels that advise the government on preventive care, the Advisory Committee on Immunization Practices and the Health Resources & Services Administration, may have made similar recommendations that will prevent some kinds of care from losing coverage, Donovan said.

Still, because of the ruling, people in their late 40s may face higher costs for colorectal screenings.

Similarly, certain lung cancer screenings for adults between the ages of 50 and 80 with a history of smoking could be subject to new out-of-pocket costs, according to the Kaiser Family Foundation.

In addition, some medications to prevent heart disease, like statins, and drugs to lower the risk of breast cancer may also be subject to copays, deductibles and coinsurance now.

Advocates are also concerned that costs will rise for PrEP, a medication highly effective for preventing H.I.V.

Although the decision is likely to drive up health-care costs for some people, Kosali Simon, professor of health economics at the O’Neill School at Indiana University, said there was little reason for panic just yet.

“Many preventive care services are not covered by this decision,” Simon said.

Insurers are also not likely to make changes to their coverage in the middle of the plan year, she added. That means any reduced coverage might not kick in until 2024. It’s also possible insurers will wait until the legal disputes over the provision are resolved before amending their policies.

Health plans will still be required to ensure no copays for many preventive services, including birth control and mammograms, Simon said. Some states have their own mandates, meanwhile, around free preventive care.

Those who are worried about changes to their health-care coverage should call their insurer and ask about any upcoming scheduled appointments, Donovan said.

Whatever you learn, Donovan said, “We recommend going forward with any planned appointments. These preventive services may save your life.”