Abstract

Elizabeth Kaplan and Anu Dairkee, The Broken Link: Braidwood, the United States Preventive Services Task Force (USPSTF), and the Health Equity Implications of Losing Free Access to Preventive Care, 50 American Journal of Law & Medicine 100 (2024) (178 Footnotes) (Full Document)

Preventive care has significant capacity to help individuals avoid disease or, if that is not possible, detect disease earlier, when there is a better chance for cure, making survival more likely and improving quality of life during treatment for patients and their families. In addition, recent and ongoing efforts to improve preventive care recommendations hold promise for a future where preventive care more effectively meets the needs of groups who are disproportionately burdened by disease. Increasing access to and use of preventive care can, therefore, be a powerful tool in addressing health disparities and improving health outcomes for systemically marginalized populations. While much work remains necessary to enable these individuals to access preventive care interventions, many of the innovative health initiatives of the last decade -- such as those aimed at addressing the social determinants of health, a key to improving health equity -- assume that preventive care itself will be free to the patient. Thus, ensuring that this remains so is also critical to equity.

In this Article, we will explore the link between the Affordable Care Act (ACA) preventive care mandate, which ensures that most individuals with private health insurance can access certain recommended preventive services without cost-sharing, and efforts to close health equity gaps. We will analyze why the mandate is so important to these efforts, especially in the context of innovative health care delivery and improved preventive care recommendations. We will then discuss these issues in the context of Braidwood Management, Inc. v. Becerra and the threat it poses to continued assurances that services recommended by the U.S. Preventive Services Task Force (USPSTF) will be covered without cost to patients. Specifically, we will focus on the USPSTF as a source of evidence-based standards for preventive care that considers the most up-to-date research and, especially in recent years, embraces a health equity lens.

To illustrate how the preventive care mandate may impact health equity, we focus on cancer and HIV. In Part IV.A, we highlight key disparities in incidence and mortality rates for colorectal, lung, cervical, and breast cancer, and explain how current and future USPSTF recommendations may help reduce those disparities if access to recommended preventive services remains assured. In Part IV.B, we highlight disparities in the U.S. HIV epidemic and explain how certain preventive services recommended by the USPSTF show significant promise for helping to end the epidemic if use of those services is increased rather than reduced. If Braidwood is upheld, affordable access to these preventive services will be jeopardized, threatening to reduce their use among populations that stand to benefit the most from them. This would set us back in the fight to reduce longstanding and entrenched disparities in cancer and HIV. Moreover, cancer and HIV are only two of many conditions that could be negatively impacted by Braidwood, the effects of which could reverberate broadly across the U.S. health care system

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Cancer and HIV are dramatic examples of conditions that are associated with significant health disparities, and that can be mitigated or avoided through preventive care -- but they are not the only examples. Many other conditions are also associated with substantial health disparities, such as cardiovascular disease and preeclampsia in pregnant patients. If Braidwood is upheld, zero-cost coverage of preventive services for these and many other conditions would be at risk.

The ACA's guarantee that most people with private health insurance can access these preventive services at no cost is not in and of itself a solution to these disparities, which are highly complex and intertwined with racism and socioeconomic inequality. Rather, the preventive services mandate is a floor upon which researchers seeking to address health disparities can build, including through innovative strategies to reach and support systemically marginalized communities in accessing care, and through efforts to ensure that preventive services recommendations are responsive to the needs of populations disproportionately impacted by preventable conditions. As we have discussed, both types of innovations presume that individuals will not be discouraged from utilizing care that is recommended for them due to cost.

Much more work remains necessary to ensure that lifesaving preventive services for cancer, HIV, and other conditions reach the populations that stand to benefit the most from them. Affirming Braidwood -- and setting federal regulation of coverage of preventive services back more than a decade -- would likely impede that progress.

Acknowledgements. Elizabeth Kaplan's and Anu Dairkee's work was supported in part by a grant from the Commonwealth Fund.