PCG: Where is “Prevention” in the ACA Replacement Debate?

Where is “Prevention” in the ACA Replacement Debate?
By Coy-Jones Health Public Consulting Group February 2017

The main goal of the Affordable Care Act (ACA) was to extend insurance coverage to millions of Americans left out of the health insurance markets, such as low-income parents ineligible for Medicaid or individuals unable to access employer-sponsored coverage. Rightfully, the terms of the ACA “Replacement” debate have been framed around alternative ways for meeting this goal, with most replacement plans distinguished and measured by the various mechanisms they propose to substitute for the insurance exchanges and Medicaid expansion measures used by the ACA to improve Americans’ access to health care.

But since the sweeping legislation of ACA was designed to transform the health care landscape and affects nearly all aspects of the health care industry, it is impossible to reduce the goals of the ACA to a single set of policy objectives. A less-emphasized intent of the law was to shift the priorities of the health care system from merely treating illness to promoting prevention and population health. In looking at the programs and provisions at stake in ACA repeal and replacement, it’s important to ask: what is the status of “prevention” in the replacement debate? How do alternative proposals address expanded access and funding to prevention services mandated by the ACA?

Before answering those questions, it’s helpful to look a little closer at what the ACA itself did to improve the availability of preventive services. Although the major provisions in the law pertain to the private insurance market and to Medicaid, the ACA also implemented new preventive services for Medicare and additional funding sources for public health programs.

Probably the most transformative initiative was the inclusion of a wide range of prevention services in the ACA’s Essential Health Benefit requirements for private insurance. These services include a number of cancer and chronic disease screenings, children’s screenings, women’s services, immunizations, and sexually-transmitted disease screenings. Coverage for these screenings was also extended to Medicare, with seniors receiving 100% coverage for an expanded list of preventive services, including some cancer screenings such as colorectal cancer.

On the Medicaid front, the expansion itself was perhaps the most important prevention effort, considering the more generous prevention in most states’ Medicaid programs relative to private insurance.

Finally, the ACA established an additional fund, the Prevention and Public Health Fund, to address chronic underfunding of state public health programs as well as finance new federal public health programs administered by the Centers for Disease Control (CDC). This fund targets the increased incidence of chronic diseases such as diabetes and heart diseases, as well as providing education dollars for public health concerns like suicide, smoking, and neo-natal care. With nearly a billion dollars available through the fund, states have become increasingly reliant on the fund to supplement declining state dollars to fund public health prevention efforts.

Significantly, while replacement plans aim to address the broader access issues raised by ACA repeal, none of the major contenders preserve the key prevention measures established through the law.

When it comes to preventive services covered through private insurance, most of the alternatives propose to pare down these coverage requirements from private insurance plans in order to reduce premiums and offer affordable, high-deductible plans. Many health care experts are skeptical that monies saved through Health Savings Accounts (HSAs) will be used to cover out-of-pocket costs for health screenings, especially for low-income families or individuals managing more pressing chronic health issues. Alternative proposals would lead to the same consequences for Medicare coverage, where the alternative plans aim to roll back ACA coverage requirements.

While the fate of the gains for prevention services depend largely on whether contender proposals continue to allow Medicaid expansion, the new administration is likely to halt new coverage requirements around women’s services, particularly coverage for contraception, which has been challenged repeatedly by religious conservative groups. Many conservative policy experts also question the rules around the public health fund, with some critics deeming it a “slush fund,” while others object to the lack of discretion given to states to fund efforts based on perceived need. Unlike many aspects of ACA repeal, most strategies for repeal of the fund provisions do not include a delay-period and go into effect immediately.

Although replacement alternatives are still being hammered out, and none of those proposed so far have garnered wide consensus, prevention does not currently appear to be a major priority for those seeking a fresh approach. This could be troubling news for many states, which have increasingly adopted a public health approach to their wider health care reform efforts. An about-face in federal priorities could throw a wrench in planning efforts to focus on integrating health and social service interventions and managing population health more holistically. Preventive services are central to these health strategies, both as a long-term investment in improving outcomes as well as substantial cost-containment measure for managing the health expense of a rapidly aging population.