On Thursday, a federal judge ruled against an Affordable Care Act (ACA) provision requiring health plans to cover preventive care, including cancer and chronic disease screenings and pregnancy care. Several industry groups have pushed back on the "deeply flawed" ruling, arguing it will negatively impact patients' health.  

Judge rules against ACA preventive care provision

Judge Reed O'Conner of the U.S. District Court for the Northern District of Texas on Thursday ruled that the ACA provision requiring health plans to cover care and treatments recommended by the U.S. Preventive Services Task Force (USPSTF) is unconstitutional.

According to O'Conner, USPSTF violates the U.S. Constitution's appointments clause since its members were not appointed by the president and approved by the Senate. Instead, the 16 members, who are primarily physicians and scientists, are chosen by HHS leaders. 

The decision builds upon a prior ruling from September, in which O'Conner ruled that required coverage of PrEP, an HIV prevention treatment, violated the Religious Freedom Restoration Act and that the USPSTF was unconstitutional. The new ruling, which went into effect immediately, applies nationwide.

Now, health plans are not required to cover any of the recommendations for preventive services made by USPSTF since 2010 when the ACA first went into effect. This includes updates to previous guidance, as well as new recommended screenings for anxiety in children, unhealthy drug use, and weight gain in pregnant individuals.

Recommendations made by USPSTF prior to 2010 or from other agencies, including Health Resources and Services Administration and the Advisory Committee on Immunization Practices, will not be affected.

How will patients be affected?

Since the ruling, several experts have voiced concerns that coverage of preventive services will be in jeopardy as health plans create future contracts. According to the New York Times, the ACA's preventive services requirement potentially affects all Americans with private health insurance, or roughly 150 million people nationwide.

"What Judge O'Connor's ruling would do, if it stands, is open up preventative services to the same kind of negotiations that other medical services are open to," said Seth Chandler, a professor at the University of Houston Law Center. Going forward, insurers could choose to charge a co-pay for certain preventive services or only cover select services.

However, Matt Eyles, president of health insurer trade group AHIP, noted that "there will be no immediate disruption in care or coverage" as insurers review the ruling and its potential impact on consumers. Since most plans run on the calendar year, preventive services are expected to be covered through the end of the year.

But many providers say it is likely the ruling will negatively impact patient care and health, especially among those who are most vulnerable, going forward. Without guaranteed coverage, some patients may forego preventive care in the long-term, which will lead to worse health outcomes and increase the overall cost of care.

"There's a lot we don't know about the impact of this ruling," said Carolyn Witte, CEO at Tia, a women's healthcare provider. "However, women are already facing a 'triple threat' to their health in this country - a growing primary care shortage, mental health epidemic and reproductive health crisis. This ruling makes the triple threat even worse, at a time when the stakes for women's health have never been higher."

Industry groups react to 'deeply flawed' ruling

So far, several industry groups, including health insurers and medical organizations, have spoken out against the ruling.

"We know these effective interventions prevent disease and save lives," said Kaiser Permanente. "As we've seen most recently during the pandemic, millions of Americans facing economic uncertainty have been able to count on the ACA for coverage, regardless of their health status or preexisting conditions."

Similarly, Blue Cross Blue Shield of Massachusetts said it is "deeply concerned that this decision will create consumer confusion about the coverage and cost of important preventive services."

The American Medical Association (AMA) has also expressed disappointment in the ruling. In a statement, AMA president Jack Resneck Jr. said the organization is "alarmed by [the] deeply flawed court ruling in Texas."

"Providing insurance coverage for screenings and interventions that prevent disease saves lives—period," Resneck said. "Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients."

A group of 23 national health associations, including the American Health Association, the American Cancer Society Cancer Action Network, and more, also released a joint letter pushing back against the ruling.

"Our organizations are deeply disappointed in today's decision," the organizations wrote. "We serve millions of people living with serious medical conditions who depend on preventive services to live healthy lives. … This decision directly threatens these benefits and would result in a return to financial and other barriers proven to discourage Americans from obtaining lifesaving, preventive care."

What happens next?

On Friday, the Department of Justice (DOJ) filed an appeal against the ruling. "For over a decade, the Affordable Care Act has ensured that millions of Americans have access to critical preventative health care. The Department of Justice has filed a notice of appeal in this case," a DOJ spokesperson said.

According to the Times, the federal government is also expected to pursue a stay of the ruling, which would prevent it from going into effect during the appeals process. However, the White House has not yet indicated when it will do so.

"This case is yet another attack on the Affordable Care Act," said White House press secretary Karine Jean-Pierre. "Preventive care saves lives, it saves families money and protects and improves our health."

Going forward, the Biden administration "will continue to fight to improve health care and make it more affordable for hard-working families, even in the face of attacks from special interests," Jean-Pierre added. (Owermohle, STAT+ [subscription required], 3/30; Morse, Healthcare Finance, 3/31; Goldstein, Washington Post, 3/31; Shabad, NBC News, 3/30; AP/NPR, 3/30; Kliff, New York Times, 3/31; Hudson/Berryman, Modern Healthcare, 3/31; Ollstein, Politico, 3/30; Taylor, Becker's Hospital Review, 3/31; Bettelheim, Axios, 3/31; Asser, HealthLeaders, 3/31; Stolberg/Abelson, New York Times, 3/30; Appleby/Andrews, Kaiser Health News, 3/30)