Abstract

Excerpted From: David Gartner, Preventive Care and Health Equity: The Educational Divide, 50 American Journal of Law & Medicine 121 (2024) (61 Footnotes) (Full Document)

In March 2023, the United States District Court in the Northern District of Texas determined that much of preventive care coverage required under the Affordable Care Act (ACA) was unconstitutional. The ruling means that the preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) since 2010 are no longer required to be covered by insurance without a cost to patients. Under the ACA, preventive services with strong evidence ratings that are recommended by the USPSTF are required to be fully covered by private insurance plans and state Medicaid expansion programs. The implications of the case are profound when it comes to the nation's leading causes of mortality and the significant inequities that continue to shape health outcomes.

In 2021, about one in four deaths in the United States involved cardiovascular disease (CVD) as an underlying cause. That year, CVD caused 931,578 deaths in the United States. Specifically, heart disease has been the leading cause of death for about 100 years. This disease is estimated to touch nearly half of all adults in the country, and its burden falls unequally across a range of demographic groups. Among these disparities is a growing gap based on education.

In 2016, the USPSTF issued a recommendation that doctors prescribe statin therapy for all adults between forty to seventy-five years old with at least one risk factor for CVD and a greater than ten percent risk of experiencing a cardiovascular event, such as a heart attack or stroke. Pursuant to the preventive care provisions of the ACA, this recommendation meant that eligible patients could not be charged for the cost of statins. Instead, an insurance provider would typically absorb the cost of these medications.

The preventive services provisions of the ACA expanded patient access to important interventions to enable earlier diagnosis and treatment for the leading causes of death in the United States. The district court's decision in Braidwood Management, Inc. v Becerra alters this basic formulation and, if upheld, would likely trigger significant out-of-pocket costs for access to statins.

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Cardiovascular mortality is higher in the United States than in comparable high-income countries, and the United States is unique among its peers with respect to the growing divergence in health outcomes between college graduates and those who have not completed college. A decade ago, scholars recognized that life expectancy gains in the United States were not keeping pace with those of other industrialized nations. In response, some highlighted the potential for a focus on educational attainment to enhance health outcomes and significantly reduce health disparities. For those in the United States with a college degree, life expectancy rose until the beginning of the COVID-19 pandemic. The magnitude of life expectancy gains for U.S. college graduates between 1992 and 2019 were second only to the overall gains in the best performing high-income country: Japan. By contrast, the United States ranked last among twenty-two high-income countries in terms of overall life expectancy for those nearly twenty years before the pandemic.

One key to explaining this growing divergence is that the life expectancy for those in the United States without a college degree peaked in 2010. Since then, overall life expectancy in the United States remained essentially flat before the pandemic while other high-income nations continued to register significant gains. In many ways, the recent crisis of life expectancy in the United States is a product of the experience of the two-thirds of Americans without a college degree.

The district court holding in Braidwood, if upheld by reviewing courts, will likely worsen existing disparities in life expectancy in the United States. The preventive coverage at risk involves the diseases that cause the greatest mortality. Heart disease remains the leading killer in the United States -- and yet the ruling would impose new cost barriers on the most widely prescribed treatment for preventing cardiovascular mortality. The existing data on the impact of copays on preventive service uptake and mortality rates strongly suggest that such a change would have a disproportionate impact on those with less education.

Effectively reversing these growing mortality disparities in the United States requires a broader range of strategies at the individual and community levels. Recent work found that including such socioeconomic risk factors in clinical decision-making reduced socioeconomic disparities. Incorporating socioeconomic factors like educational attainment into clinical decision-making might better address the cardiovascular treatment gap, even though it could raise other challenges.

A broader research agenda is needed to better understand and address the causes of growing disparities in heart health and life expectancy in the United States. More insight into the underlying mechanisms that contribute to the growing education gap is crucial to more effectively responding to this challenge. However, existing research already makes clear that reducing access to the current tools against leading causes of mortality -- like preventive services at risk in the Braidwood litigation -- will only increase the life expectancy gap in the United States.

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