The U.S. District Court recently struck down the requirement that most health plans provide coverage for certain preventative services with no cost sharing in a case called Braidwood Management Inc. v. Becerra. Cost sharing is the amount you must pay for medical services, in addition to your health insurance premium. Cost-sharing can be coinsurance or copays. It can also include your deductible and costs that lead to your out-of-pocket maximum.
What does this ruling mean for people at risk for kidney disease? We answer some questions you may have about this case and its effects on preventive health measures.
Q: What is the Braidwood case?
A: Under the Affordable Care Act (ACA), most private health insurance plans must cover, with no patient cost-sharing, recommended preventive health services that receive an A or B grade from the U.S. Preventive Services Task Force (USPSTF). The USPSTF grades preventive health services based on the evidence of the effectiveness of each recommendation. Some of the current recommended preventive services include colorectal cancer screening for adults starting at age 45; statin use for the prevention of heart disease in adults with certain risk factors; and screening for prediabetes and type 2 diabetes in adults with certain risk factors.
In the case Braidwood Management Inc. v. Becerra, the plaintiffs — a group of individuals and businesses that provide health insurance to their employees — sued the federal government, arguing that the ACA's preventive services coverage requirements are unconstitutional. The case was heard in the U.S. District Court for the Northern District of Texas.
Q: What was the U.S. District Court's ruling?
A: On Sept. 7, 2022, a District Court judge issued a ruling that found the requirement for most private health plans to cover USPSTF recommended preventive services is unconstitutional. The court's reasoning was that the USPSTF is an independent body of experts that is not supervised by the Secretary of Health and Human Services or any other federal agency. Also, the Secretary does not have any authority to direct the USPSTF on their specific recommendations or to ratify them. Therefore, the District Court reasoned that requiring health plans to cover USPSTF preventive services recommendations is a violation of the Appointments Clause of the Constitution.
On March 30, 2023, the District Court issued a ruling for the remedy to the case, striking down part of the ACA's preventive services coverage requirement effective immediately nationwide. Based on this ruling, private health plans do not have to provide no-cost coverage for preventive services that received an initial A or B recommendation or an update from the USPSTF on or after March 23, 2010 (the date the ACA was signed into law).
The District Court's ruling is being appealed to the 5th Circuit Court of Appeals.
Q: Do people still have access to no-cost coverage of preventive services while the legal process is ongoing?
A: Yes. The parties in the case came to an agreement on a stay of the lower court ruling and it has been approved by the Court of Appeals. That means people will continue to have access to no-cost coverage of preventive services while the legal process continues.
Q: If the District Court's ruling is ultimately upheld, what would that mean for people's access to no-cost preventive services, particularly for kidney disease and its leading cause, diabetes? How could this impact people's health?
A: There are currently more than 150 million people who have access to no-cost preventive services. Eliminating access to many of the current recommended preventive services with no cost-sharing would have a significant, negative effect on the ability of people to get the care they need in a timely and effective manner.
Research has shown that prevention measures and early detection and treatment of health conditions leads to improved health outcomes, as well as cost savings to the patient and the health care system. Research has also demonstrated that relatively small levels of cost sharing are associated with reduced use of care, even for necessary services. Additionally, a recent survey found that 2 in 5 respondents said they would likely skip 11 of 12 preventive services currently covered by the ACA if they had to pay out-of-pocket.
Currently, there is no recommendation from the USPSTF on kidney disease screening. However, as noted above, there is a recommendation on diabetes screening, and diabetes is the leading cause of kidney disease. The USPSTF recommendation on diabetes screening was most recently updated in August 2021, and it recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity.
If the District Court's decision is upheld, health plans would not have to provide coverage of prediabetes or diabetes screening with no cost sharing for adults who meet those criteria. However, health plans would have to provide no-cost coverage of the USPSTF diabetes screening recommendation that existed prior to March 2010. That recommendation, from 2008, recommended screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.
The USPSTF routinely updates existing recommendations based on its review and assessment of the best available evidence. Providing coverage for the 2008 diabetes screening recommendation instead of the current recommendation could lead to more people going undiagnosed. While high blood pressure is linked to diabetes, there are many more people with diabetes or at risk for diabetes who are overweight or obese. For adults aged 35 to 70 years, the prevalence of obesity is more than 40%.
Health plans may still decide on their own to provide no-cost coverage for diabetes screening based on the current USPSTF recommendation, however, eliminating the requirement for plans to provide these services with no cost sharing could lead to more people going undiagnosed. More people living with diabetes and not knowing they have it could then lead to more adverse and costly complications, including kidney disease.
Q: How is AKF advocating for kidney patients in light of this ruling?
A: Prior to the District Court's decision on a remedy, AKF joined a group of 16 patient organizations in submitting an amicus brief – also known as a friend-of-court brief, typically filed by a person or organization with a strong interest in the outcome of a decision – urging the U.S. District Court to preserve the preventive services coverage requirement. The brief explains how required coverage of USPSTF recommended preventive services increases access to care, improves treatment outcomes, saves lives and reduces cost burdens.
On June 27, the organizations filed an updated brief in the U.S. District Court of Appeals providing extensive scientific data.
"We remain concerned about the far-reaching consequences of the District Court's decision that could reverse years of progress on prevention, early detection and disease management," the patient groups said in a statement.