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What Health Payers Need to Know as Texas Lawsuit Threatens Preventive Care

In an effort to close the gap in disparities of healthcare coverage, access to preventive care was an integral focus in the creation of the Affordable Care Act (ACA) as it requires all health plans to eliminate cost sharing for various screenings, vaccinations, immunizations and counseling. In 2020 alone, more than 152 million Americans reaped the benefits of this coverage and screenings were at an all-time high. 

However, a group of employers and individuals in Texas have recently made headlines by filing a lawsuit pushing for the ACA’s required preventive services to be revoked, stating the mandatory provision of such services at no cost is unconstitutional. The plaintiffs argue that health insurance plans should not include free coverage of preventive services, including screenings for breast cancer, lung cancer, cervical cancer, colorectal cancer, heart disease, hepatitis, and hypertension – along with immunizations for polio, measles and other diseases as it goes against religious beliefs. The lawsuit also called for all FDA-approved contraception to be paid for out of pocket, in addition to consumers being responsible for payment around preeclampsia screening, breastfeeding information and services. 

In September 2022, federal district court Judge, Reed O’Connor, ruled on the case. While he did not issue an order blocking enforcement of the coverage requirements, he did find that part of the preventive coverage requirements to be unconstitutional – specifically those around HIV and contraception. Further hearings are to be held to fully determine what preventive coverage O’Connor will be demanding is unconstitutional and if he will push for a nationwide injunction. 

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While the ramifications of this lawsuit are still unknown, the possibility of the loss of preventive care is shaking up the healthcare industry and causing many consumers to rethink their current health plans, especially women, children and those in the LGTBQ+ community as they have the most to benefit from the coverage of preventative care. 

Why is preventive care so important? 

Preventive care’s main objective is to catch something before it’s too late. A lack of screenings or immunizations can lead to a domino effect of health concerns down the line, inevitably causing someone to experience life-threatening situations. Doctors cannot take the necessary precautions to reduce risks or accurately treat patients without preventive testing and treatments. 

For women, preventive care is extremely vital in pregnancy and postpartum. It’s been shown that increasing preconception and postpartum insurance coverage resulted in lower maternal mortality rates. If this lawsuit is overturned, women will lose access to services that support healthy pregnancies. Women in the United States already have the highest rate of maternal deaths than any other industrialized country, and a loss of preventive services will create even more barriers for women to receive necessary treatments.

Preventive care is also crucial in protecting the youngest of Americans: newborns. The ACA currently covers universal newborn hearing screening and bilirubin concentration screening which is central to a baby’s development. The Act also allows women to access breastfeeding services and equipment, and without it, women would struggle to breastfeed for the recommended period of time. Unfortunately, a lack of this access can have a strong negative impact on the overall health of both babies and their mothers.  Additionally, the loss of breastfeeding services and equipment will make it more difficult for women to return to work, which will have a significant impact on low-income families. 

How will this lawsuit impact health plans moving forward? 

If nationwide injunction on preventive care is to be entered, there are various changes that could take place in the health insurance industry. If this ruling goes into effect, it’s most likely that insurers and health plans will offer very different cost-sharing levels for services. This will make it even more difficult for consumers to compare plans, ultimately increasing the likelihood that consumers will choose a plan that does not fit their needs and will end up with the wrong type of coverage. 

Overall, the current volume of Americans who rely and benefit from preventive care coverage will undoubtedly decrease and cause severe impact on life spans and general access to healthcare. Payers will have the opportunity to be patient advocates and provide coverage for the necessary care that Americans need to live healthy lives.

Ryan Bullock is Chief Operating Officer at Aeroflow Healthcare.

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