section 2713: eliminating cost-sharing for preventive services
Section 2713 of the Public Health Service Act as amended by the ACA requires non-grandfathered private insurance plans to provide first-dollar coverage for preventive care services. With the intent to include all segments of the population, Congress selected three organizations to determine covered preventive services: the United States Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), and the Health Resources and Services Administration (HRSA).
table 1. recommending bodies for preventive services
| Recommending Entity | Supporting Agency | Recommended Interventions | Appointments |
|---|---|---|---|
|
United States Preventive Service Task Force (USPSTF) |
Agency for Healthcare Research and Quality (AHRQ) |
Clinical preventive services |
By the director of AHRQ |
|
Advisory Committee on Immunization Practices (ACIP) |
Centers for Disease Control and Prevention (CDC) |
Vaccines |
By the HHS Secretary |
|
Health Resources and Services Administration (HRSA) Women’s Preventive Services Guidelines (WPSI) |
N/A (federal agency) |
Women’s preventive health care services |
N/A (federal agency) |
Source: Hughes IV R, Chappel N, and Walters W. 23 Sep 2022. Health Affairs. DOI: 10.1377/forefront.20220922.150344
The USPSTF assigns health care services a letter grade. Services that receive an “A” or “B” rating are considered high-value, and are therefore covered without cost-sharing under Section 2713. The current list of preventive services includes a variety of counseling services, immunizations, and screenings for cancer and treatable chronic diseases, such as diabetes and hypertension.
Impact of the preventive service mandate
Section 2713 is one of the most popular provisions in the ACA, and has increased screenings, improved health outcomes, and reduced racial disparities in health care access. The U.S. Department of Health and Human Services estimates 152 million Americans have access to additional preventive care with zero cost-sharing, especially among Black Americans, Latinos, Asian Americans and Pacific Islanders, American Indians/Alaska Natives, and individuals living in states that expanded Medicaid.
A literature review conducted by members of the V-BID Center concluded that cost-sharing elimination, such as Section 2713 of the Affordable Care Act, leads to increased use of preventive services. Low-socioeconomic groups and those who experience the greatest financial barriers to care appear to benefit the most from cost-sharing elimination. Evidence from studies examining the impact of the ACA indicate increased colon cancer screening, vaccinations, use of contraception, and chronic disease screening.
Today’s Fifth Circuit ruling maintains the status quo (for now) for the highly popular ACA policy that eliminates out-of-pocket costs for many high-quality preventive services – enhancing access for over 200 million Americans – that have been proven to prevent diseases or to detect conditions while they’re still treatable.
This decision provides a welcome reprieve to a possible Braidwood ruling that would limit the removal of cost-sharing to only those preventive services recommended by the USPSTF before the passage of the ACA in 2010. Such a change would have enormous clinical and equity implications.
Dr. A. Mark Fendrick
Legal challenge to 2713: Braidwood v. becerra
On March 30, 2023, Judge Reed C. O’Connor of the U.S. District Court for the Northern District of Texas ruled in favor of Braidwood Management Inc., blocking enforcement of Section 2713. The ruling deemed the U.S. Preventive Services Task Force (USPSTF) recommendations unconstitutional because its members are not presidentially appointed or Senate-confirmed. Additionally, the decision concluded that requiring employers to cover Pre-Exposure Prophylaxis (PrEP) medications for HIV prevention without cost-sharing violates the Religious Freedom Restoration Act. These decisions raise broader concerns about contraceptive coverage and other preventive services mandated by the ACA.
The case has now reached the U.S. Supreme Court, where the justices will determine the constitutionality of Section 2713. The outcome could have sweeping implications for access to preventive services, particularly for underserved populations.
Future directions
The US Fifth Circuit Court had previously allowed the Department of Justice’s appeal to stay Judge O’Connor’s ruling, maintaining the status quo temporarily. However, the Supreme Court’s decision will ultimately determine the future of preventive care access under the ACA.
Congress could resolve the constitutional concerns by legislatively granting the U.S. Department of Health and Human Services Secretary authority over USPSTF recommendations. Such an amendment would protect Section 2713 from legal challenges and ensure continued access to preventive services without cost-sharing.
Imposing cost-sharing for preventive services would reverse progress in expanding access to high-value care and could exacerbate health disparities among low-income, minority, and LGBTQ+ populations. Employers overwhelmingly support full coverage of preventive services, recognizing the long-term health and economic benefits.
Recent evidence suggests that the implementation of out-of-pocket costs would have a minimal impact (less than one-half of 1 percent) on aggregate employer health care spending.
Research indicates that 80% of employers are unlikely to impose cost-sharing even if the mandate is overturned, citing the minimal financial impact on overall healthcare spending and the significant health benefits of incentivizing preventive care.
As the Supreme Court considers the case, the nation awaits a pivotal decision that could redefine preventive care access and equity in the U.S