Inside Braidwood V. Becerra: Prevention Innovation at Risk

Prevention needs innovation just as much as treatment. Its coverage also needs a mandate.

Judicial branch involvement in healthcare can help or harm. In either case, the impact may have both immediate and ripple effects.

Enter Braidwood Management, Inc. et al. v. Xavier Becerra et al., the case that could decide the fate of the ACA’s Preventive Services Mandate. The immediate impact? Whether select preventive services will remain free in the U.S. The ripple? Whether the ruling will restrict coverage for even more preventive services at a time of tremendous uptake and innovation.

Part two of HealthLeaders’ Braidwood Analysis series explores these questions. Catch up on part one here.

Recap: Braidwood status and impact

Since the 5th Circuit Court of Appeals issued a stay of the District Court's ruling:

• Nearly two dozen healthcare stakeholders have filed amicus briefs to support the Preventive Services Mandate
• The government has submitted its formal appeal
• By November 3, all respondents must submit briefings and the Fifth Circuit begins its review

Details: Services impacted

In addition to blocking required PrEP medication coverage (HIV prevention), the District Court ruling included services "recommended or updated by the U.S. Preventive Services Task Force (USPSTF) on or after March 23, 2010." This impacts select USPSTF service recommendations with an A or B rating, which represent “a high or moderate net benefit for patients.

This is a big deal. The Kaiser Family Foundation notes that the USPSTF is one of four "expert medical and scientific bodies" that make ACA-required preventive service recommendations. As mentioned in part one of this Braidwood analysis series, the USPSTF scope spans adult and child preventive services such as reproductive health and pregnancy, chronic conditions such as cancer, infectious diseases, and immunizations. Not all of these services are impacted (e.g., free coverage for mammograms or cervical cancer screenings), but some very innovative ones are.

Since 2010, these include and in order of the percentage of enrollees affected:

• Statins for those at risk for cardiovascular disease (adults aged 40–75)
• Hepatitis c screening for (adults aged ≥ 22)
• Lung cancer screening (all adults)
• Breast cancer risk-reducing drugs (at-risk women aged ≥35)
• Hepatitis b screening (non-pregnant, at-risk adults aged ≥ 22)

See the USPSTF website for the complete A/B recommendations list.

Case study: Colorectal cancer screening

Another no-cost service that Braidwood would eliminate? Colorectal cancer (CRC) screenings for younger adults (aged 45-49). This comes at a time when:

• CRC cases and deaths are rising in this age group
• Workforce shortages and the pandemic have created colonoscopy backlogs
• Multiple, at-home screening options are available

At-home screening is an effective CRC detection option and colonoscopy alternative for average-risk patients. It meets the Triple Aim (cost, population health, patient experience) and improves access. This is all particularly true for Black Americans and for those facing social drivers of health barriers, where CRC risks have also increased.

Prevention innovation at risk?

At-home CRC screening is an example of a significant preventive services innovation. The field has come a long way. 

Diagnostics and screening are “not a static space,” noted Lisa Lacasse, president of the American Cancer Society Cancer Action Network, in a Protect Our Care press briefing earlier this year. “There's so much innovation that's coming on the market . . . If there are barriers to access, then that's just one more reason that innovation may slow down a little bit.”

And while most women are still waiting for something that feels like innovation during their annual mammogram, cervical cancer screening — in addition to CRC — has innovated to improve access, cost, and quality. HPV testing now allows low- to average-risk women aged 30–65 to be screened every five years.

Studies show that many of these women believe annual screenings are still required. This highlights the other important facets of prevention innovation: process, strategy, communication, education, and stakeholder collaboration.

Advances in these less-thought-of areas helped create the Affordable Care Act, its Preventive Services Mandate, and require coverage design innovation to keep pace with diagnosis and treatment.

If some preventive services fall, what’s next?

Does Braidwood represent a risk to preventive care at large? Yes. The Plaintiffs in Braidwood are already seeking a wider restriction of required no-cost preventive services.

It is widely known that the ACA has improved access to and use of prevention care. A Peterson-KFF Health System Tracker analyzing 2019 data found that “at least 1 in 20 privately insured people [5.7%] received . . . ACA preventive services or drugs potentially affected by Braidwood Texas district court ruling. According to the American Community Survey, 173 million non-elderly people have private health insurance coverage. Based on this, we estimate up to nearly 10 million people could face higher out-of-pocket costs if the district court ruling stands and insurers ultimately decide to implement cost-sharing.”

Does Braidwood also raise larger questions about whether prevention coverage has innovated as much as it could or should? Also yes, particularly payers already stating that competitive pressures could drive them to drop no-cost coverage if the Preventive Services Mandate falls.

Stay tuned for part three—the slippery slope of payer coverage commitments—and click here for the part one Braidwood case recap.