- Between 21% and 61% of patients incur same-day costs while accessing supposedly free preventative care as part of the Affordable Care Act’s free preventative care mandate, according to a new study published in Health Affairs.
- Researchers found that patients can incur costs due to same-day care, associated laboratory work or follow-up visits, with mean same-day out-of-pocket expenses rising inversely for lower metal tiers, and bronze enrollees experiencing the highest costs.
- The results come as the ACA preventative care mandate faces a federal court battle. Last week, the Biden Administration filed a notice to appeal a March 30 federal court ruling that blocked the mandate requiring health plans to fully cover preventative medical services including cancer, HIV and diabetes screenings.
The ACA preventative care mandate requires compliant plans to fully cover certain first-line preventative services with no patient cost sharing.
However, researchers in the Health Affairs study found that preventative services like colonoscopies could generate between $329 and $941 in out-of-pocked expenses for patients. They also pointed to studies that found that cost sharing for mammograms and colonoscopies did not change significantly after the implementation of the ACA, and that out-of-pocked expenses persisted almost a decade after the legislation’s 2010 passage.
The study comes as medical groups decried a Texas judge’s March 30 ruling to block the ACA preventative care mandate, with the American Medical Association saying that free preventative care saves lives.
“Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients,” said American Medical Association President Jack Resneck in a statement.
Judge Reed O’Connor in U.S. District Court for Northern Texas blocked the mandate, ruling that the volunteer group tasked with creating the preventative mandate was not appointed appropriately under the constitution.
Researchers in the study found that more than a third of patients incurred out-of-pocked expenses on the day of their ACA-mandated free preventative medical care service, suggesting limitations of the ACA’s first-line care mandate.
“If an inconclusive mammogram prompts an additional same-day study, such as tomosynthesis or ultrasound, these services drive up the experienced cost of breast cancer screening for patients,” researchers said. “Influenza vaccinations and annual wellness visits are commonly received as part of comprehensive health check-ups, and yet components of these checkups may increase patient cost sharing.”
Researchers analyzed a private database to analyze claims from 2016 to 2018, and also found that utilization of preventative services generally increased with actuarial value among the four non-cost-sharing-reduction metal tiers of bronze, silver 70, gold and platinum plans.
The drop in preventative care utilization may suggest that patients in lower metal tier plans anticipate experiencing costs with “free” services, the study noted.
Of the services that generated same-day costs, researchers found that annual flu shots were the most likely to generate fees at a mean value of $26 per vaccine.
The study found that same-day, out-of-pocket expenses were highest for colonoscopies, especially anesthesia, with a mean cost exposure of $324 and $365 for two types of anesthesia.
“Patients enrolled in ACA-compliant health plans in the individual market should be able to access many preventive care services at zero cost,” the study said, adding: “Our results suggest that additional steps must be taken to ensure that the ACA’s intended coverage of preventive care is upheld both in letter and in spirit.”