A September ruling by Texas federal district judge Reed O’Connor struck down part of the Affordable Care Act’s (ACA) preventative coverage mandate. But the move is unlikely to lead employers to impose coinsurance payments for certain preventive goods and services that they are now required to cover in full, health policy analysts say.
O’Connor ruled Braidwood Management Inc. v. Becerra that it was unconstitutional under the ACA for the U.S. Preventive Services Task Force to require the vast majority of health plans nationwide to provide free preventive services. At the time of publication of this article, O’Connor had not issued a formal appeal or decided the scope of the ruling, which he could only apply to the plaintiffs suing (a management services company in Katy, Texas), or nationally to most health departments. plans. Either way, a call from the Biden administration is certain.
However, “I just don’t see employers backing down (on paying for preventive care coverage) even if they’re allowed to,” said Paul Fronstin, director of health benefits research at the Institute nonprofit Employee Benefits Research Institute (EBRI) in Washington, DC. “Most employers recognize the importance of covering high-value services, and we’re not talking about large sums of money here.”
Although O’Connor’s decision opens up, at least in theory, the opportunity for employers and insurers to reduce some of their costs, Tim Jost, professor emeritus at Washington and Lee University School of Law in Lexington , Virginia, and frequent contributor to the Commonwealth Health Policy Fund Commentary, does not see Congress impatient for people to start paying for things that are now covered.
“I think it will be difficult for any politician to run against prevention services,” Jost said.
A representative for at least one insurer said he had not heard from any of his employer clients discussing reductions in funding for prevention services.
“It’s not a trend we’re seeing or even hearing about,” said Debra J. Williams, director of sales and marketing at Blue Cross Blue Shield of Massachusetts. “Preventive care is essential to our employer clients’ strategy, and they want to make this avenue affordable and accessible. For example, the vast majority of our self-funded customers have adopted our $0 co-pay strategy for virtual primary care (telehealth). “
Fronstin said the likely lengthy appeals process surrounding O’Connor’s decision likely means very little, if anything, will change in how preventative services are covered.
“Things are obviously evolving until we get more information from the court about the scope of this case,” he said. “But just because employers are allowed to charge cost sharing doesn’t mean they will.”
Approval of the status quo
In October, shortly after O’Connor’s decision, Fronstin and his EBRI colleagues conducted a pulse study among 25 large employers which together represent 600,000 employees and 1.2 million insured people. Among the results:
- 80% of responding HR decision-makers said they would continue to cover prevention services in full. This was true even if they were allowed to impose cost sharing.
- Only 8 percent would mandate cost sharing for at least some preventive services.
- 12 percent answered: “It depends.”
When EBRI asked respondents why they would continue to provide preventive services at no cost to their members, a number said that covering preventive services in full “encourages their use, promotes better health, prevents more serious illnesses, is insignificant in terms of costs and saves money in terms of costs. the long term.”
Focusing on PrEP costs
O’Connor’s decision also held that the plaintiff’s religious beliefs were violated under the Religious Freedom Restoration Act, given the plaintiff’s religious objection to coverage for a preventative medication of HIV known as pre-exposure prophylaxis (PrEP) for employees.
In a subsequent EBRI research noteFronstin and colleagues found that the per-patient cost of these drugs is relatively high, at $13,814 per year, but that still represents only a small portion of a typical employer’s overall health care spending.
“Because so few enrollees use PrEP medications (about 0.17 percent of all members), the total cost of these medications represents only 0.41 percent of employers’ total health care spending.” , the researchers discovered. “If, for example, employers charged patients a 20 percent co-payment for PrEP medications, their spending would decrease by less than one-tenth of 1 percent.”
For other commonly used preventive screenings, the savings that could be achieved by introducing 20 percent cost sharing – typical of non-preventive care – were even lower: employers would save 0.11 percent on costs. -payments for breast cancer screenings and 0.15 percent for colorectal screenings.
Some recommended services impose no additional cost, EBRI researchers said, because they are often provided as part of a routine office visit, such as screening for hypertension, smoking and a unhealthy weight.
Incentives for preventive care
Joe Vitale, director of human resources at Oberlin College in Oberlin, Ohio, said the university has provided additional incentives to receive preventative care for its approximately 1,700 employees, all of whom are covered by a health plan at high deductible linked to health savings accounts (HSA). ). For example, the employer HSA contribution amount has been tied to participants seeing their doctors for annual physicals or undergoing biometric exams, although these requirements have been suspended due to COVID-19.
“Additionally, we have decided to concentrate all employer-paid HSA funding at the beginning of the month into a single lump sum in January,” to encourage preventative care such as annual physicals, Vitale said.
Employee Demographics
Jost expressed concern that small employers might choose to charge for prevention services even if larger employers don’t.
“If you’re talking about insured employers, and especially small employers, the situation can look quite different,” he said.
The employee profile can also make a difference. In a small company, “if you have (many) employees over 55 who are having colonoscopies and whatever else, it may be quite different than if you’re in the tech industry and you have a lot of young employees who don’t have one. many prevention services,” Jost emphasized.
However, he added, given the possibility of a lengthy appeals process in this case in the federal courts, it is unlikely that anything will happen to the benefit mandates until 2024 or beyond . And, given that an important basis for O’Connor’s decision was a narrow ruling that the way the U.S. Preventive Services Task Force is named is unconstitutional, insurers and employers who still want to provide preventive services and encouraging their use could use guidelines from other sources. – medical specialty societies, for example – should Congress not address the decision through subsequent legislation.
Another option for employers who decide to add additional cost sharing to reduce their costs could be to provide some preventive services and medications for free while adding a copay for others.
“There are many ways to control costs,” Fronstin said. “Shifting costs onto employees is one solution. Trying to get better deals with your providers is another, like contracting with surgical centers of excellence and incentivizing your employees to go there.”
Taking the center of excellence strategy a step further, employers could begin contracting with colonoscopy providers and incentivizing employees to go to that provider as another way to control costs.
Greg Goth is a freelance health and technology writer based in Oakville, Connecticut.
