The Biden Administration has filed an appeal with the Fifth Circuit over a federal judge's decision to nationally invalidate Affordable Care Act mandates guaranteeing free coverage for certain cancer screenings and preventive care services. Healthcare legal experts agree, saying that without them, hospitals will face greater challenges in preventing patients from deterring or delaying care, which puts them at greater risk of late-stage diagnoses that are harder to treat.

The U.S. Preventive Services Task Force, a panel of the ACA, recommends types of preventive care that insurers should cover at no cost for roughly 150 million people with private health coverage, as well as those using the ACA marketplace.

In a 2020 legal challenge, Braidwood v. Becerra, eight individuals and two businesses, all from Texas, said these mandates are unlawful because the USPSTF members who made them were not appointed by the president, violating the appointments clause of the U.S. constitution. They also said they should not have to cover HIV-preventive measures, such as PrEP, STD testing and contraceptives, as doing so violates their religious rights under the Religious Freedom Restoration Act of 1993.

“Coverage for those services violates their religious beliefs by making them complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman," wrote Judge Reed O'Connor, of the U.S. District Court for the Northern District of Texas, in his ruling.

O'Connor originally sided with the plaintiffs in September, but waited until March 30 to determine that the verdict should apply nationwide, reported Reuters.

Which services are at risk?
The ruling applies to any mandates made after the ACA's enactment in 2010, which include screenings for anxiety in children, unhealthy drug use and weight gain in pregnant women, and PrEP, a daily pill for preventing the transmission of HIV, reported The New York Times.

While mandates made prior to 2010, such as mammograms for breast cancer, will not lose coverage, insurers are no longer obligated to abide by new guidance issued by the USPSTF on when it is necessary to conduct those services. For example, they will not have to cover CT colonography and stool-based tests as colorectal screenings for patients starting at age 45, a recommendation made in 2021 in response to what the Task Force said was a rise in young-onset colorectal cancer.

The decision also affects services like heart screenings and tobacco programs, as well as recommendations on when patients should be eligible to undergo mammo for breast cancer detection; CT for lung cancer; and PSA testing for prostate cancer. Some experts have criticized these guidelines, saying that they do not go far enough or incorporate important factors for accurately determining risks of developing diseases.

Earlier this year, clinicians at the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group, which includes the University of Texas MD Anderson Cancer Center, said in a study that more advanced risk-based lung cancer screening models that account for more risk factors may be more cost-effective and yield more quality-adjusted life years than USPSTF guidelines.

But some research has shown that these guidelines address care gaps, such as a report that showed USPSTF 2021 update for lung cancer screenings to be responsible for reducing screening eligibility gaps between races from 10% in 2013 to 2%.

Additionally, Andrew Twinamatsiko and Zachary Baron, associate directors of the Health Policy and the Law Initiative at the O'Neill Institute for National and Global Health Law at Georgetown University, told HCB News that ACA mandates encourage patients to get screened before showing signs of ailments, a sign that conditions are late-stage and harder to treat.

“If this requirement is set aside, like the Braidwood court has done, that means hospitals will, in the long-run, be dealing with patients that have delayed treatment or care, which is bound to put greater stress on the health system overall,” they said.

What happens next?
Twinamatsiko and Baron told HCB News that the decision will create a lot of "confusion," as different insurers make different stipulations as they see fit. “They [hospitals and health systems] will have to encourage their patients to accept lifesaving services and at the same time commit resources to help navigate the confusion that the decision has created with respect to the coverage of such services."

In a statement, Lisa Lacasse, president of the American Cancer Society Cancer Action Network, also said the ruling would prevent early cancer detection and treatment.

American Medical Association president Jack Resneck said patients "will be subjected to needless illness and preventable deaths.”

The Justice and Health and Human Services departments are reviewing the ruling to determine next steps. “We will do everything we can to protect and defend Americans’ rights to the healthcare they need and deserve,” said HHS spokeswoman Kamara Jones.

In a statement, Matt Eyles, president of AHIP, the largest health insurance trade group, says coverage will not change immediately. “We fully expect that this matter will continue on appeal, and we await the federal government’s next steps in the litigation, as well as any guidance from relevant federal agencies.”