60% of Privately Insured Patients Utilized Some ACA Preventive Care

March 21, 2023 - Researchers from the Peterson-Kaiser Family Foundation (KFF) Health System Tracker discovered that in 2018, nearly 100 million privately insured Americans, or 6 out of 10, utilized some of the preventive care mandated as part of the Affordable Care Act (ACA).

However, an unfurling legal battle surrounding the ACA-mandated preventive care could trigger a domino effect, impacting out-of-pocket costs and access to these essential services.

The analysis examined the share of privately insured people who received ACA preventive care and utilized services or medication in 2018, using two claims databases to assess utilization: the Merative MarketScan Commercial Claims and Encounters dataset for large group enrollees and the Enrollee-Level External Data Gathering Environment (EDGE) Limited Data Set (LDS) for individual and small group market enrollees. 

Concentrating on specific age groups, genders, and diagnoses, the research offers a look into pre-pandemic preventive care usage. Researchers argued that the use of pre-pandemic data offers a more accurate reflection of typical preventive care utilization, as opposed to more recent data influenced by atypical pandemic behaviors.

The findings showed that the rate of preventive care utilization was similar across various markets. Researchers noted that 61 percent of patients with coverage from large employers and 57 percent of fully insured small employers accessed preventive care. Similarly, those in the individual market, purchasing insurance via ACA Exchanges or health plan websites, presented a 55 percent utilization rate.

The most commonly received preventive care services among privately insured patients were vaccinations (excluding COVID-19 vaccines), wellness visits, and screenings for heart disease, cervical cancer, diabetes, and breast cancer.

The study findings revealed disparities in preventive care utilization, with men less likely to access these services than other demographic groups.

Conversely, women, children, and older adults were found to be more likely to receive preventive care, partly because some ACA preventive services are recommended only for specific groups based on age or gender. For example, mammograms are recommended for women aged 50 to 74, while many vaccinations are recommended for young children.

In 2018, around 7 in 10 children with private insurance utilized preventive care; rates were consistent across boys and girls, researchers found. About 7 in 10 young women with private coverage used preventive care into adulthood, but young men had much lower rates (about 3 in 10). While preventive care utilization rates increased for men in middle age, disparities persisted compared to women.

As of yet, the ACA requires most private health plans to provide in-network preventive care services without any cost-sharing, as recommended by the US Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), and Health Resources and Services Administration (HRSA). These no-cost preventive services include screenings, immunizations, behavioral counseling, contraceptives, and medications that prevent worse health outcomes.

As research indicates, ACA-mandated preventive care coverage has considerably enhanced affordable access to healthcare services, including cancer screenings, vaccinations, and contraceptive care.

Since the ACA was passed into law in 2010, many legal challenges have been filed in state and federal courts, with over 2,000 cases seeking to challenge the mandate.

The latest legal challenge occurred on September 7, 2022, when the Northern District of Texas District Court declared that the ACA delegation to USPSTF was unconstitutional.

In the Braidwood Management v. Becerra case, the plaintiffs argued that the mandate was unconstitutional because members of USPSTF, ACIP, and HRSA were not appointed by the president nor confirmed by the Senate. Additionally, the plaintiff mentioned that the requirement to cover pre-exposure prophylaxis (PrEP) to prevent HIV violates religious rights.

“Overturning any part of the ACA’s preventive services coverage requirement would leave coverage decisions to health plans. If not for the ACA’s preventive services coverage mandate, health plans would have discretion to apply cost-sharing for these services, which could include copayments, coinsurance, or deductibles,” the KFF researchers stated.

“Missed or delayed screenings could lead to later diagnoses of health conditions that might have been more treatable or less costly if caught earlier. If health plans shift out-of-pocket costs toward preventive care, though, that could result in other services having lower out-of-pocket costs or some health plans having slightly lower premiums.”

Although the mandate for preventive services coverage still stands, the court’s decision could impact preventive care for all patients, researchers mentioned.