Preventing Preventive Care

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Speaker A: You.

Speaker B: Just a heads up.

Speaker B: We know what’s happening in Manhattan.

Speaker B: We’ll get into Trump’s arraignment and the fallout from it tomorrow on the show.

Speaker B: Think about the last time you tested your blood pressure or you had a mammogram or you got a flu shot.

Speaker B: That’s preventive care, and it’s kind of really important.

Speaker B: 75% of US.

Speaker B: Healthcare spending goes toward treating chronic and preventable diseases, the kind of stuff preventive care is designed to find.


Speaker B: But health reporter Julie Rovner says people don’t always get it.

Speaker A: A lot of Americans don’t have what’s called a regular source of care.

Speaker A: They don’t have a doctor that they go to regularly.

Speaker A: And that’s where most of this care happens.

Speaker A: It’s an annual physical or some kind of visit for a non emergent ailment.

Speaker A: And a lot of people don’t have that.

Speaker B: In fact, according to the National Institutes of Health, just 8% of Americans actually go to those routine screenings.

Speaker A: It’s the thing that you just need to schedule, but you never get around to it.


Speaker A: I mean, there is resistance to it.

Speaker A: It’s not like when you have a toothache and you have to go to the dentist.

Speaker A: It’s like when you have to go to the dentist to get your teeth cleaned.


Speaker A: It’s harder to fit preventive care into a busy schedule.

Speaker B: When the Affordable Care Act was passed back in 2010, lawmakers decided to grease the wheels a little.

Speaker A: What studies have found is that if there’s any sort of friction, as they call it, if people have to pay out of pocket at any point, they’re less likely to get preventive care.

Speaker A: So what the Affordable Care Act did is it said virtually every health plan had to provide most types of preventive care with no copay or upfront payment.


Speaker A: And now it’s not to say it’s free.

Speaker A: A lot of people say it’s free preventive care.

Speaker A: It just means that it’s built into the premium, and it’s not very expensive in general, so it doesn’t increase the premium very much.

Speaker B: And so far, it seems to have worked.

Speaker A: It’s been very popular.

Speaker A: We’ve seen increases in the types and the amount of preventive care that people have sought and got since the Affordable Care Act really took effect in 2013, 2014.

Speaker B: That’s why, for a lot of Americans, it was a big curveball when a federal judge struck it down last week.


Speaker C: A federal judge in Texas has ruled that employers cannot be required to cover key preventative health care benefits under the Affordable Care Act.

Speaker C: It jeopardizes free coverage of a wide range of services for some 160,000,000 Americans.

Speaker C: The Biden administration is expected to request a stay on the ruling.

Speaker B: Larry Levitt today on what next.

Speaker B: What happens when preventive care comes with a price tag?


Speaker B: I’m Mary C.

Speaker B: Curtis in for Mary Harris.

Speaker B: Stick around.

Speaker D: You know, it’s been a long running saga with the Affordable Care Act, or Obamacare, as it’s come to be known.


Speaker D: How long have you been covering the.

Speaker A: Twists and turns from the very beginning, from before President Obama was even Senator Obama, there were actually a number of Senators and members of the House who were putting together the framework of what would become the Affordable Care Act.

Speaker A: So President Obama was a little bit of a late comer to that effort.

Speaker A: So it goes back a long ways.

Speaker D: Would you say that Obamacare was under attack since the very beginning?

Speaker A: Absolutely.

Speaker A: The day it was signed, we had the first lawsuit that was filed against it.

Speaker A: New York.

Speaker A: The Supreme Court has cast arguably the most important vote in a generation on health care affecting every single American and Georgia.


Speaker E: It is President Obama’s signature legislation, and the Supreme Court has upheld the requirement that every American buy health insurance.

Speaker E: We want to go straight to ABC’s Terry Moran.

Speaker A: Every time somebody says this is the last lawsuit, it’s not the last lawsuit.

Speaker D: We know what it was supposed to be.

Speaker D: We know what compromise made the Affordable Care Act.

Speaker D: How much has the legislation changed or been chipped away over the years?

Speaker A: A fair bit.

Speaker A: A lot of the more controversial pieces surprise, surprise have gone away.

Speaker A: Republicans and Democrats kind of backed off a lot of the taxes that we’re supposed to pay for it, including taxes on medical devices.


Speaker A: Now, why would we want to discourage medical innovation?

Speaker A: Only in Washington would you impose a tax on life saving medical devices and then think you’re going to help reduce health care costs.

Speaker E: And guess what?

Speaker A: A very controversial tax on very expensive health plans went away.

Speaker F: It was supposed to only target overly generous health plans the Cadillacs on the healthcare highway, so to speak.

Speaker F: Mr.

Speaker F: President.

Speaker F: In practice, however, the tax has become more of a Ford focused tax.

Speaker A: The Republicans, in their tax bill made the mandate go away.

Speaker G: It took away people’s choices.

Speaker G: It forced them to buy expensive insurance wasn’t right for them.


Speaker G: Mr.

Speaker G: President, it’s time for the insurance mandate to go away.

Speaker A: So, as it turned out, the mandate was not, in fact, key to getting people to sign up.

Speaker A: What was key to getting people to sign up was giving them subsidies enough that they could afford health insurance.

Speaker B: That brings us to this latest challenge.

Speaker B: A federal judge has struck down a key ACA provision, one that required private insurers to provide preventive care at no cost to patients.

Speaker B: Here’s the thing, though.

Speaker B: It only applies to some types of preventive care, specifically, the types of care recommended by something called the US.


Speaker B: Preventive Services Task Force.

Speaker B: This judge says the task force violates something called the Appointments Clause, a rule stating that important federal decisions have to be made by people appointed by the President and approved by the Senate.

Speaker A: It’s important to say that there were three different entities that determine what preventive care is to be offered.


Speaker A: Two of them come under hearsa the Health Resources and Services Administration in the Department of Health and Human Services.

Speaker A: And at least so far, the judge in this case has said that those are okay.

Speaker A: So that includes most of the women’s health care and a lot of the children’s screening.


Speaker A: There’s another group, vaccines are recommended by ASIP the Advisory Council on Immunization Practices.

Speaker A: Again.

Speaker A: They report to the Department of Health and Human Services.

Speaker A: They’re appointed, so the judge says they’re okay.

Speaker A: It’s really just this third group of services that are recommended by the US.

Speaker A: Preventive Services Task Force, which is a volunteer group of experts that basically go in and they rate preventive services based on how well they work, what the evidence base is for, whether they actually prevent people from getting sick, and they give them letter grades, ABCD or I.

Speaker A: And basically what the Affordable Care Act said is that anything that USPSTF rates an A or a B will have to be covered without upfront cost in the Affordable Care Act.

Speaker A: That’s the piece that, at least for the moment, has been stricken from the Affordable Care Act.

Speaker B: That means any treatment recommended by the US Preventive Services Task Force since 2010 wouldn’t be covered, including medications that prevent HIV, statins that lower cholesterol, medications that reduce the risk of breast cancer, and a lot of others.

Speaker B: Julie says the ability to rank preventive treatments and recommend new ones is really important.

Speaker A: These recommendations get updated and changed.

Speaker A: There’s been back and forth about what age women should get mammograms and how often, and that keeps changing according to the evidence.


Speaker A: We get new evidence and the recommendations change.

Speaker A: So, I mean, ironically, one of the things that this court decision would do if it stands because the judge said he was only going to make this illegal back to March 23, 2010, the day the Affordable Care Act got signed.

Speaker A: So all of these recommendations that were being followed before then, it’s what we would go back to so they wouldn’t be the latest the newest information that experts have on the type of preventive care and how often this care should be provided.

Speaker D: We know that these entities, I think they put about 80 items on the list that health insurers must cover.

Speaker D: You’ve talked about some of them.

Speaker D: Can you give some more examples?

Speaker A: The big one and the one that sort of got this lawsuit to the judge was prep for HIV.

Speaker A: This is a pill that people who are at high risk of getting HIV can take, and it works extremely well at preventing HIV.

Speaker A: And the doctor who actually sued said that he thinks that he didn’t want to have to offer that to his employees because it encouraged dangerous homosexual practices and that violated his religion.

Speaker A: So that’s a big one because that recommendation didn’t come until sort of the mid 2010s, so it would be stricken by this ruling.

Speaker D: Julie, could you tell me more about the person who actually brought this suit in front of the judge.

Speaker A: He is very well known in Texas.

Speaker A: He’s a doctor named Stephen Hotsy’s, and I’m a Texan.

Speaker G: And for crying out loud, we’re the most conservative state in the entire union, and we do not like Obamacare down here.


Speaker G: It’s not popular nationwide, and it’s even more unpopular in Texas.

Speaker G: And Texans have always stood up against tyrannical forms of government encroachment, and this is federal encroachment into what should be an individual personal responsibility.

Speaker A: He’s a GOP.

Speaker A: Mega donor.

Speaker A: He’s given a lot of money to the Republican Party.

Speaker A: He’s a longtime activist against LGBTQ requirements of any form.

Speaker A: And last year, he was actually indicted as part of a scheme to try and prove voter fraud in Harris County, where Houston is located.

Speaker A: So he’s quite a colorful guy who’s brought this lawsuit.

Speaker D: So how many people will be affected by this ruling?

Speaker A: Potentially 150,000,000 people.

Speaker A: It’s not just people with Affordable Care Act plans.

Speaker A: It’s people with all non grandfathered private health insurance plans.

Speaker A: Non grandfathered plans are the ones that were in effect prior to 2010, so there aren’t that many of them left.

Speaker A: So it really is a large number of people.

Speaker A: And this is one of the most popular pieces of the law.

Speaker A: And it’s one of the most used pieces of the law.

Speaker D: What about people with public insurance, such as Medicare or Medicaid?

Speaker A: They are mostly bound by this as well.

Speaker A: Medicaid has long paid for preventive services anyway because people with Medicaid don’t have a lot of money.

Speaker D: So according to this ruling, insurers will not have to cover free preventive care that this panel, the US.

Speaker D: Preventive Task Force, recommends.

Speaker D: So what types of preventive care will no longer be covered?


Speaker D: We’ve talked about the prep.

Speaker D: Anything else?

Speaker A: Yeah, there are new recommendations for screenings for depression and anxiety, for lung cancer in particular.

Speaker A: There are now scans for lung cancer that are recommended screenings for hypertension and other kinds of heart disease.

Speaker A: So there’s a very long list of preventive services that doctors are supposed to ask about, or medical professionals, if you’re not seeing a doctor to screen when people come in for routine care and those are at risk now, remember, it’s not that insurers won’t cover them.

Speaker A: It’s that insurers won’t cover them with no upfront costs.

Speaker A: Most of these things were covered before most insurers wanted to cover preventive care, but often it came with a copay or it would be part of your deductible.

Speaker D: Well, it kind of makes sense if you’re a health provider, to want to get to these illnesses or conditions before that’s.

Speaker A: Right.

Speaker A: And the issue here is the incentives for the insurers.

Speaker A: Will the insurers stop doing this if they no longer are required by law and they’re sort of competing incentives.

Speaker A: On the one hand, insurers compete against other insurers and for employers and for people who are choosing plans in the Affordable Care Act.

Speaker A: And people might want the plans that make it easier to get preventive care.

Speaker A: On the other hand, the irony about providing preventive care is that people don’t always stay with their insurers long term.

Speaker A: So if an insurer pays for all this preventive care keeps the person from getting sick, the person may be with another insurance plan who would reap the benefit of that.


Speaker A: So there’s a push and pull both ways with this.

Speaker D: Let’s be clear though not all preventive care will be affected.

Speaker D: What will insurers still be required to cover?

Speaker A: Vaccines that are recommended by ASIP, which is a separate entity, the Advisory Council on Immunization Practices, and basically Women’s and children’s health screening that come from a different agency.

Speaker A: But all preventive care without costs, without upfront cost, could be at risk.

Speaker A: But at the moment, it’s only the preventive care that’s recommended by the US.

Speaker A: Preventive Services Task Force.

Speaker A: We don’t know, as I say, what happens when this goes up to the next level, to the Fifth Circuit Court of Appeals and possibly to the Supreme Court.

Speaker B: After the break, the ACA could be heading to the Supreme Court yet again.

Speaker B: But what happens when it goes before the current lineup of justices?

Speaker D: It sounds like people have been bracing for this decision since last September.

Speaker D: That’s when the same judge, Judge O’Connor, declared a key provision of the Affordable Care Act unconstitutional.

Speaker D: Tell us about what happened then.

Speaker A: Right so, we already knew that he had decided that this violated the Appointments Clause, that the Preventive Services Task Force recommendations were going to not be allowed.

Speaker A: The question was, what were the remedies going to be?

Speaker A: Was it just going to apply to this employer and there were six individuals who were part of this case, or was it going to apply on a wider level?

Speaker A: Now, this is rather famously the same judge who decided that the entire Affordable Care Act was unconstitutional back in 2018.


Speaker E: Well, good morning to you.

Speaker E: The Affordable Care Act has stood up to prior legislative and legal challenges and has been upheld twice by the Supreme Court.

Speaker E: But the judge cited another landmark piece of legislation passed just last year in striking Obamacare down this time.

Speaker A: Eventually the Supreme Court overruled that and.

Speaker D: Said, no, let’s go back to the same judge.

Speaker D: But the ruling from last week, if the decision stands, it could take us back to before the 2010 health care law was put into place, when it was up to insurers to decide which preventive services to cover.

Speaker D: So what happens now?

Speaker A: That’s right.

Speaker A: Probably nothing happens in the short run.

Speaker A: Insurance contracts tend to run on a full year basis.

Speaker A: A lot of insurers covered preventive care.

Speaker A: Most insurers covered preventive care prior to the Affordable Care Act.

Speaker A: All the Affordable Care Act did is say you have to offer at no upfront cost.

Speaker A: I wouldn’t expect very many insurers to stop covering it altogether, although in theory they could.

Speaker A: And I’m not even sure how many insurers are going to stop covering it without copay because it’s popular and people are used to it.

Speaker A: And that we discovered that when the entire Affordable Care Act was at risk, insurers probably weren’t going to stop covering kids up to age 26.

Speaker A: Again, it’s popular and insurers compete with each other.

Speaker A: So on the one hand, you don’t want to be the most expensive insurer.

Speaker A: On the other hand, you want to offer a product that people are going to want to buy.


Speaker D: So what have the reactions been to this ruling from Democrats and from Republicans?

Speaker D: I’m thinking quite different.

Speaker A: I haven’t seen a lot of reaction from Republicans.

Speaker A: Again, preventive care is very popular.

Speaker A: I have seen Democrats and all manner of public health groups decrying this ruling saying that the preventive care is really important and as you mentioned, not enough people get it anyway.

Speaker A: So anything that makes it harder to get is probably not good for America’s health writ large.

Speaker A: And there’s a lot of concern about that.

Speaker A: I would think that Congress could theoretically fix this with a one page bill that says the US.

Speaker A: PSTF recommendations have to be approved by the Secretary of Health and Human Services.

Speaker A: That would basically solve the legal problem here.

Speaker A: I don’t know that anybody’s going to suggest that.

Speaker A: I don’t know if they could do that even if they wanted to, because doing anything with the Affordable Care Act in Congress is very controversial and very difficult.

Speaker A: But if they wanted to fix it, they could.

Speaker D: Well, with any far reaching decision like this, there’s going to be pushback and an appeal, right?

Speaker A: Both sides are likely to appeal.

Speaker A: We already know that the Justice Department is appealing, but the plaintiffs are likely to appeal because they only got those recommendations from the Preventive Services Task Force struck.

Speaker A: They also wanted the recommendations for immunizations and for women’s and children’s health screenings to be struck, and those weren’t.

Speaker A: So we could see both sides going to the next level saying, we want more of this decided in our favor because it was technically a split decision.


Speaker D: So the Biden administration, through the Justice Department and the Department of Health and Human Services, they are pushing back, right?

Speaker A: Yes, they are appealing.

Speaker A: The issue here is that this is part of the Fifth Circuit Court of Appeals, which is one of the most conservative appeals courts in the country.

Speaker A: So the likelihood of getting a panel that would overturn this is not high.

Speaker D: What about a stay on the Texas court’s decision?

Speaker D: Is that a possibility?

Speaker A: It is a possibility.

Speaker A: They would go to the Fifth Circuit and ask the Fifth Circuit to stay it.

Speaker A: We’ll see if the Fifth Circuit does that again, if the Fifth Circuit declines to stay it, they could ask the Supreme Court.

Speaker A: We don’t know what the Supreme Court thinks about this either.

Speaker A: We just know that the Supreme Court is a lot more conservative than it was even the last time it considered a question about the Affordable Care Act.

Speaker D: As you said at the beginning of our conversation, you have been following this since before Barack Obama was president, and it has always been something that’s been controversial.

Speaker D: But we’ve also seen that so many of these provisions of the Affordable Care Act have become more and more popular, and politicians see this as well.

Speaker D: Insurers see this.

Speaker D: I’d like to just know what you think about this, about how long it took to get this and how it’s been really under attack ever since and where you think this is going.

Speaker A: Well, of course, Nancy Pelosi was derided when she said that people are going to have to find out what’s in it before they like it.


Speaker A: That turned out to be exactly true, sort of.

Speaker A: The more people found out about what was in it, the more like, oh, is this one of the they have to cover my kids up to age 26.

Speaker A: That’s cool.

Speaker A: Oh, they have to cover preventive care without a copay.

Speaker A: That’s cool.

Speaker A: Oh, if I lose my job, I can maybe get financial help to buy health insurance that I couldn’t otherwise afford.

Speaker A: That’s cool.

Speaker A: So there’s a lot of things in this law that turned out to be very, very popular.

Speaker A: And I think one of the frustrations for a lot of Democrats is that there’s a lot of things that people like that they don’t know were part of the Affordable Care Act, including this preventive care requirement.

Speaker A: So there are things that the Affordable Care Act brought that people don’t know about, but the things that people do know about tend to be pretty popular.

Speaker D: Do you think it will always be with us in some form?

Speaker A: That’s a very good question.

Speaker A: I remember being told after every major court case, it’s like, okay, now the Affordable Care Act is safe.

Speaker A: Okay.

Speaker A: Now the Affordable Care Act is safe.

Speaker A: There’s basically been one of these lawsuits pretty much every two years, so who knows?

Speaker D: Thank you, Julie, for coming on what next?

Speaker A: Thank you for having me.

Speaker B: Julie Rovner is chief Washington correspondent for Kaiser Health News.

Speaker B: That’s the show.

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Speaker B: And I’m Mary C.

Speaker B: Curtis, columnist at Roll Call and host of its Equal Time podcast.

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