Is Your Preventive Care Still Covered? What to Know After Judge Strikes Down Part of ACA

A federal judge in Texas has overturned a very popular part of the Affordable Care Act (ACA): free coverage of many preventive healthcare services.

The U.S. Department of Justice is likely to ask for a hold on the judge’s ruling while the case is appealed, which would keep coverage of services in place as the case winds its way through the courts. For now, though, there’s a great deal of confusion among patients, and concern among doctors, who worry patients will stop getting needed preventive services.

“The American Medical Association (AMA) is alarmed by [Thursday’s] deeply flawed court ruling in Texas that jeopardizes access to preventive health services guaranteed under federal health reform, including drugs preventing HIV transmission,” said Jack Resneck, Jr., MD, president of the American Medical Association, in a statement.

“A critical section of the Affordable Care Act required insurers and health plans to cover dozens of preventive health services with no cost to patients…for the early detection of potentially fatal medical conditions, including cancer, hypertension, diabetes, and sexually-transmitted infections,” Resneck said. “Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients.”

The judge’s ruling only applies to some preventive services—those recommended by the U.S. Preventive Services Task Force (USPSTF), a voluntary group of health providers who make recommendations on national guidelines such as taking statins to lower cholesterol.

It’s the fact that USPSTF recommendations are voluntary that invalidates free coverage of the services it recommends, according to the ruling in Texas. The judge said to be valid enough for coverage of its recommendations, the USPSTF members would have to be appointed by the President and confirmed by the Senate.

It's not just coverage through federally-funded marketplace plans, like Obamacare, that are at stake. Most private health plans do not require any payment—including copays or deductibles—for preventive services because of the ACA requirement. Without that requirement, things may change for nearly everyone.

The ruling doesn’t apply to preventive services that have to be authorized by the federal government, including pregnancy and well child doctor visits, along with many vaccinations, according to experts from health research group Kaiser Family Foundation (KFF) which held a reporter’s briefing on the decision just a few hours after the judge’s ruling.

Your Preventive Services Are Still Covered for Now

Experts don’t think there will be an immediate effect of the ruling because the Justice Department will step in for now.

“It’s [likely] that the administration will immediately appeal this…and will be asking for a stay,” said Laurie Sobel, associate director for Women’s Health Policy at the Kaiser Family Foundation. “We’ll have to see how the litigation plays out to see when anything could take effect.”

It’s also unlikely that insurers will end coverage of preventive services or start charging copays anytime soon, because most insurance contracts are annual ones and run through the end of December 2023, Natalie Davis, CEO of bipartisan health insurance advocacy group United States of Care, told Verywell.

That means that many insurance firms can’t change provisions for insurance beneficiaries yet. It also buys time for several protective measures to possibly happen:

• The Department of Justice can appeal the decision
• States can write their own laws if they choose to require that insurers cover preventive services
• Employers—who provide coverage for millions of Americans—can mandate free preventive services in their contracts with insurers

An issue brief by the Employment Benefit Research Institute in October found that even if free preventive services were to be invalidated for insurance plans under the ACA, many employers would retain them. That’s because encouraging employees to use preventive services can save employers money on healthcare costs later on.

Plus, private insurers aren’t necessarily on board with the ruling. This sentiment was made clear in a statement released after the judge’s ruling by Matt Eyles, president and CEO of AHIP, an association which represents many large health insurers.

“Every American deserves access to high-quality affordable coverage and health care, including affordable access to preventive care and services that help avoid illnesses and other health problems,” Eyles said. “As we review the decision and its potential impact with regard to the preventive services recommended by the United States Preventive Services Task Force, we want to be clear: Americans should have peace of mind there will be no immediate disruption in care or coverage.”

Don’t Cancel Medical Appointments

There’s likely to be news in the next few days about any effects of the ruling. In the meantime, if you’re scheduled for a health exam, don’t cancel.

“I would advise people to contact their insurer directly and clarify with them about the cost,” Leana Wen, MD, an emergency physician and a professor of health policy and management at George Washington University, told Verywell. “The company should state that preventive services are still covered. Call first and confirm, then ask for this information in writing if you want to be extra certain. The key is not to delay; so many people have postponed cancer screenings and other routine checkups due to COVID-19, and they should not put off care that could detect problems early.”