Research shows that cost-sharing, even in small amounts, reduces the likelihood that people will use preventive services. As a result, the Affordable Care Act (ACA) contains a provision that mandates group health plans and health insurer coverage of certain essential health benefits and preventive services without cost-sharing by patients. The ACA’s list of preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) includes several radiology exams, like breast, lung and colon cancer screenings, that have received a rating of “A” or “B” from the USPSTF.
However, this widely popular provision is in jeopardy. A federal judge for the U.S. District Court for the Northern District of Texas ruled on March 30 that the ACA provision requiring health plans to cover care and treatments recommended by the USPSTF is unconstitutional. According to Judge Reed O’Conner, this provision of the ACA violates the U.S. Constitution’s appointments clause since members of the USPSTF are not Senate-confirmed. Instead, the 16 members of the USPSTF, who are primarily physicians and scientists, are chosen by U.S. Department of Health and Human Services leaders.
The decision builds upon a prior ruling from September in which O’Conner concluded that coverage of an HIV prevention treatment violated the Religious Freedom Restoration Act and, separately, that the USPSTF was unconstitutional. At that time, O’Connor requested supplemental briefings addressing whether the government should be entirely blocked from requiring health plans to cover services identified by the USPSTF, or whether the decision should apply only to the plaintiff in this case.
The latest ruling, which went into effect immediately, now applies nationwide. However, most insurance plans run on the calendar year, so preventive services are expected to be covered through the end of the enrollment year.
As a result of this ruling, health plans are no longer required to cover any of the recommendations for preventive services made by USPSTF since 2010, when the ACA was first signed into law.
Recommendations made by USPSTF prior to 2010, including screening mammography, will not be affected. However, private insurers could rescind coverage of CT colonography and lung cancer screening CT. Insurers may now choose to charge a co-pay for preventive services or cover only select services, which would tragically erase recent progress in improving access to screening for these high-mortality diseases.
In 2016, USPSTF designated CT colonography as a recommended screening test for colorectal cancer starting at age 50 and continuing until age 75. In May of 2021, USPSTF expanded the age range recommended for colon cancer screening to patients ages 45 to 49, granting millions more Americans private insurance coverage for this vital screening test. This coverage provided hope on the heels of American Cancer Society data showing that the proportion of colorectal cancer occurring in people under age 55 doubled between 1995 and 2019.1
While we continue to advocate for Medicare coverage of CT colonography, mandated private payer coverage was a huge step in the right direction. Simply, this coverage saves lives.
In March 2014, the USPSTF recommended annual lung cancer screening in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The USPSTF expanded the eligible age range to 45 to 80 and reduced the pack-year requirement to 20 in March 2021.
Early detection of lung cancer through screening has been shown to reduce mortality by 20%.2,3 Providing insurance coverage for lung cancer screening CT saves lives. Yet, lung cancer screening rates remain abysmally low with 5.8% of eligible patients receiving the recommended screening nationwide.4
We can make every effort to improve our screening tools, provide education on their benefits and build programs that navigate patients through the system. But without coverage, our patients will never have access to these lifesaving services in the first place.
Following the March 30 decision, the U.S. Department of Justice quickly filed an appeal. Multiple physician groups and patient advocacy groups, including the ACR, voiced concern and expressed support for the appeals process. 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.
The ACR will continue to advocate for access to evidence-based screening services, especially for our most vulnerable patients with the lowest ability to pay out-of-pocket health expenses.