Introduction
A recent ruling by the U.S. Court of Appeals for the 5th Circuit puts at risk the Affordable Care Act’s (ACA) popular and successful requirement for no-cost preventive health services. In the case of Braidwood Management Inc. v. Becerra,1 the court ruled that requiring insurers to provide the no-cost care is unconstitutional. However, the court allowed the provision to remain temporarily in effect for most of the country while litigation continues. (see text box below for more information)
While the ACA is best known for its successes at advancing affordable, equitable, and comprehensive health coverage for all Americans,2 equally important are its prevention-related provisions, including the requirement for insurers to cover select preventive services at no cost. The law has also provided select health care workers financial help for student loans and additional training, and it established the Center for Medicare and Medicaid Innovation (CMS Innovation Center) and other platforms for testing alternative payment and health care delivery models to improve health outcomes. This issue brief explores these components of the law and their impacts to date.
Spotlight on:
The ACA requires coverage of certain preventive services without patient cost sharing
The ACA made coverage of more than 100 preventive services more comprehensive and accessible.3 Section 2713 requires most private health plan policies beginning on or after September 23, 2010, to cover routine vaccinations, preventive care for adults, preventive care for children, and preventive care for women4—with no out-of-pocket costs (such as coinsurance, deductibles, and copayments) to the patients. These ACA coverage rules have been widely celebrated as a major success for saving lives, expanding access to care, and improving long-term health.5 The zero cost-sharing preventive service requirement is one of the most popular provisions of the ACA: In 2023, 82 percent of Americans had a “very favorable” or “somewhat favorable” view of the preventive services provision.6
Undergirding the ACA’s preventive services provision is the requirement that insurance plans cover certain evidence-based services recommended by the U.S. Preventive Services Task Force (USPSTF), including recommended screenings such as blood pressure, diabetes, cholesterol, some cancers, sexually transmitted diseases, and depression; substance use services such as alcohol misuse, tobacco cessation, unhealthy drug use screening, and counseling; and healthy eating and weight management, among other services.7 Additionally, the law requires no-cost coverage for Advisory Committee on Immunization Practices (ACIP)-recommended immunizations that have been determined to be routine for adults or children.8 This includes vaccinations that protect against influenza; tetanus; human papillomavirus (HPV); measles; COVID-19; hepatitis A and B; respiratory syncytial virus (RSV) in infants and pregnant women; and other critical infectious diseases.9
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The ACA also requires coverage of several preventive services that the Health Resources and Services Administration (HRSA) recommends at no cost to women, including well-woman visits; birth control; breastfeeding support; screenings for a range of conditions such as cervical and breast cancer, intimate partner violence, and urinary incontinence; and USPSTF-recommended screenings for maternal depression and osteoporosis.10 In addition, the ACA requires coverage of services for children recommended by the HRSA Bright Futures program, including well-child visits; behavioral and developmental assessments; and certain screenings such as vision and hearing, lead exposure, obesity, oral health, and mental health.11
Using data from 2020, a study by the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation found that more than 230 million privately insured patients, Medicaid adult expansion enrollees, and Medicare beneficiaries can receive no-cost preventive services because of the ACA’s provisions.12 The ACA’s removal of cost sharing led to more Americans accessing blood pressure screenings, contraception, wellness visits, HPV vaccination, tobacco cessation counseling, colorectal cancer screenings, and other services—allowing for early detection, treatment, and prevention of health issues and improved long-term health outcomes.13 Increased colonoscopies and mammograms also led to reduced racial and ethnic health disparities among Hispanics and African Americans.14 For women, increased contraceptive use is associated with increased economic security in addition to health benefits: In the first year of no-cost coverage, women saved $1.4 billion on out-of-pocket costs for contraception.15 The ACA’s requirement for coverage of chronic disease screenings has helped improve outcomes in blood pressure control, glucose control, and cardiovascular health.16
What is in the Braidwood ruling?
In its Braidwood Management Inc. v. Becerra decision,17 the U.S. Court of Appeals for the 5th Circuit ruled that the ACA’s preventive services provision was unconstitutional on the grounds that the USPSTF violates the appointments clause of Article I of the Constitution, which governs how the president delegates executive authority to administration officials. The 5th Circuit agreed with the district court, holding that under the appointments clause, members of the USPSTF must be nominated by the president and confirmed by the U.S. Senate. The court declined to speak firmly on the constitutionality of services recommended by the ACIP and the HRSA, remanding the question back to the district court. The 5th Circuit did, however, narrow the remedy for its ruling to the parties in the suit. In other words, Braidwood Management and the other plaintiffs are not required to cover USPSTF services at no cost while the lawsuit continues, but the mandate holds for the rest of the nation covered by private insurance—applying to more than 150 million people.18 For the time being, this largely leaves unchanged the landscape for private health coverage for the vast majority of those people; however, the ruling created a loophole that may be exploited to create inequities in coverage. Experts expect additional legal challenges to questions left open by the decision, and it is likely that the case will eventually be appealed to the U.S. Supreme Court.19
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The ACA includes provisions to strengthen and to support the workforce that delivers clinical preventive services
The ACA contains more than a dozen provisions to train the clinical provider workforce to expand access to preventive services, conduct workforce analyses, and support new programming.20 For instance, sections 5201, 5202, and 5203 of the ACA amended the Public Health Service Act to increase federally supported medical, nursing, and pediatric health care workforce student loans, respectively.21 Section 5303 also established and improved training programs in general, pediatric, and public health dentistry.22 The ACA further reauthorized the Preventive Medicine and Public Health Training grants that support physician residency programs in preventive medicine.23 In September 2010, HHS awarded $16.8 million, mostly from the Prevention and Public Health Fund, in grants to 27 public health training centers for public health workforce training.24
The ACA has tested new models for delivering preventive services
In addition to requiring coverage of preventive services and supporting the workforce, the ACA has tested new models, such as disease-specific programs, for delivering preventive services. For instance, the National Diabetes Prevention Program (NDPP) provides evidence-based, lifestyle-change interventions that reduce the risk of developing diabetes among at-risk populations.25 Research shows that NDPP participants reduced their risk of developing diabetes by 58 percent after three years.26
Section 3021 of the ACA authorized creating the CMS Innovation Center to test new health care payment and delivery models.27 These models pay for the overall health of patients rather than the volume of services delivered, which provides an incentive for providers to prevent disease. For instance, the Innovation Center’s Million Hearts Model provided financial incentives to providers for reducing cardiovascular disease risk among their total high-risk Medicare patient populations; according to an evaluation, the model led to significant reductions in heart attacks, strokes, and heart disease-related deaths over five years.28 The Innovation Center’s State Innovation Models helped states advance population health initiatives by testing methods to improve coordination between clinical providers and community-based organizations that provide services for obesity, tobacco use, diabetes, and other chronic diseases.29 According to The Commonwealth Fund’s review of prior Innovation Center models, many models sought to address drivers of health by incorporating some degree of focus on screening for unmet needs and referrals to community-based organizations. Yet to be truly successful, the review showed, models need to strengthen financial incentives.30 The Innovation Center has recently developed new or modified models, such as States Advancing All-Payer Health Equity Approaches and Development (AHEAD) and the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model, that may provide an opportunity to do so.31
Most provisions of the ACA that focus on prevention emphasize what the Centers for Disease Control and Prevention have called “traditional and innovative clinical preventive” services.32 Beyond clinical preventive services, the ACA includes provisions to improve total population health through interventions that create healthy environments and promote health and wellness in community settings. For instance, the ACA created the Prevention and Public Health Fund (PPHF), a mandatory funding stream to support state, local, and Tribal evidence-based public health programs.33 Funded through the PPHF, the Community Transformation Grant (CTG) Program enabled states and communities to develop and implement community-driven initiatives to prevent chronic diseases such as diabetes, heart disease, cancer, and stroke.34 The ACA also established the first National Prevention, Health Promotion, and Public Health Council to incorporate health and wellness throughout federal programs and policies to achieve better health for all Americans.35 Although these and other ACA prevention programs have not been fully funded or consistently supported to reach their full potential, they highlight the notion that disease prevention must be approached holistically and embedded within broader efforts intended to improve health outcomes in order to transform health and well-being.
Conclusion
The ACA’s decade of progress ensures access to both affordable health care coverage and no-cost clinical preventive services for the majority of Americans and has helped lay the foundation for better health outcomes, disease prevention, and health promotion activities. Policymakers can build on the ACA’s successes by prioritizing and investing in interventions and population health strategies that improve health and well-being for entire communities. In light of the 5th Circuit’s ruling in Braidwood v. Becerra, Congress must also work quickly to codify legislation that would unequivocally maintain no-cost coverage for all recommended preventive services and avoid potential costly delays in care.36