Loss of ACA Preventive Care Mandate Could Impact 10M Enrollees

With the Affordable Care Act’s preventive care coverage requirement under scrutiny, Peterson-KFF researchers investigated how many Americans rely on the law’s coverage and determined that as many as 10 million people could be affected.

The researchers leveraged 2019 claims data—which would not be susceptible to the coronavirus pandemic’s impact—to assess preventive care services utilization.

The district court’s ruling specifically targeted US Preventive Services Task Force (USPSTF) recommendations, saying that employers who offer private, employer-sponsored health plans should not be required to fully cover all of the preventive drugs and services that the Affordable Care Act (ACA) demands. The court found this requirement to be unconstitutional.

Given the district court’s focus, the researchers also centered the study on USPSTF recommendations. They observed utilization for certain drugs and services that experienced changes in USPSTF recommendations after the ACA’s implementation.

This encompassed statins for adults between 40 and 75 with cardiovascular disease risk, lung cancer screenings for American adults, hepatitis C screenings for adults ages 22 and older and hepatitis B screenings for non-pregnant, at-risk adults in the same age range, and breast cancer risk-reducing drugs for women ages 35 and older who are at risk.

The study covered preventive care utilization for these drugs and services across all private markets including the large and small employer markets and individual health insurance marketplaces.

“If the Fifth Circuit Court stay is lifted and the district court’s decision is affirmed by a higher court, insurers would be allowed to introduce cost-sharing for any of the affected preventive services and drugs or exclude coverage altogether, though the latter appears to be the less likely scenario,” the researchers determined.

Overall, 5.7 percent of private payer marketplace enrollees relied on preventive care services that were covered through the ACA. That percentage represents around 10 million Americans or one out of every twenty private payer marketplace enrollees.

The share was highest in the individual health insurance marketplace where 7.0 percent of individuals used ACA-covered preventive care services. Additionally, 5.7 percent of large employer enrollees and 4.1 percent of small employer enrollees used ACA preventive care.

The results overwhelmingly reflected statin usage. Statin utilization accounted for 4.8 percent of the collective ACA preventive care usage.

However, the researchers indicated that the results might look different post-2019. After 2019, USPSTF made major changes such as recommending PrEP and colorectal cancer screenings. Moreover, the impact could grow with each new USPSTF recommendation.

A previous study from Peterson-KFF noted that six out of ten Americans used preventive care services under the ACA coverage mandate. Using 2018 data, the study found similar trends in preventive care utilization across markets. Vaccinations, wellness visits, and screenings accounted for most of the preventive care services that Americans used. Around 70 percent of children with private health insurance coverage used preventive care and the same share of young women.

The district court ruling that determined the ACA’s preventive care services requirement was unconstitutional occurred in March 2023. Since then, the Biden administration appealed the decision and the appeals court stayed the effects of this ruling until the litigation is settled.