The Affordable Care Act and State Coverage of Clinical Preventive Health Services for Working-Age Adults Jennifer L. Pomeranz, JD, MPH; Y. Tony Yang, ScD, LLM, MPH rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr

ignificant public health challenges facing the United States stem from preventable disease. The Patient Protection and Affordable Care Act dedicated substantial resources toward prevention. Among other reforms, the Affordable Care Act requires Medicaid and private health insurers to cover clinical preventive services for adults, pursuant to recommendations by the U.S. Preventive Service Task Force. This article examines the infrastructure upon which these recommendations are based, the requirements related to risk factors for leading causes of preventable disease in adults associated with tobacco and alcohol use, unhealthy diet, and inactivity, and coverage requirements for private plans and Medicaid. The article provides and assesses data comparing the health statuses of populations in and preventive services offered by states taking the Affordable Care Act Medicaid expansion versus those in states declining to expand coverage. The article suggests legislative and other methods to increase preventive clinical service requirements and notes outstanding issues for future research.

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KEY WORDS: Affordable Care Act, clinical preventive services,

Medicaid expansion, prevention, state law, working-age adults

The United States spends more than all other countries on health care1 but scores lower than its peer nations on major indicators of population health, including life expectancy.2 Significant public health challenges facing the United States stem from preventable disease,3 but the vast majority of health care dollars finance responsive clinical care at the expense of pre-

J Public Health Management Practice, 2015, 21(1), 87–95 C 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

ventive services.2 Congress passed the Patient Protection and Affordable Care Act (ACA) in 2010 to reform the national market for health care and for the first time dedicated substantial resources toward prevention. Among other reforms, Congress created the Prevention Fund4 and amended the requirements for clinical preventive services.5 The Prevention Fund has been distributed to communities in an effort to invest in population-based prevention,6,7 while preventive clinical service requirements seek to focus clinical dollars on preventive rather than responsive care. The health care system is overburdened with chronic disease in working-age adults resulting from preventable tobacco and alcohol use, unhealthy diet, and inactivity.3 Employing evidenced-based preventive clinical care services in these domains may utilize health care dollars more wisely and can ultimately save lives.8-10 The federal government and those of every state share regulatory authority over most private health insurance and Medicaid. The ACA requires certain health care plans to cover the recommended clinical preventive services graded “A” and “B” by the U.S. Preventive

Author Affiliations: Department of Public Health, Center for Obesity Research and Education, Temple University, Philadelphia, Pennsylvania (Ms. Pomeranz); and Department of Health Administration and Policy, George Mason University, Fairfax, Virginia (Dr Yang). Funding for J.L.P. was provided by the Vitality Institute as part of its broader support for a Commission on the prevention of chronic diseases among workingage Americans. The authors thank Jeffrey Levi, executive director of the Trust for America’s Health, for comments on previous drafts, and Elizabeth Garbarczyk, Health Insurance Specialist at the Department of Health & Human Services, Centers for Medicare & Medicaid Services, for research assistance. No human participants were used. The authors declare no conflict of interest. Correspondence: Jennifer L. Pomeranz, JD, MPH, Department of Public Health, Center for Obesity Research and Education, Temple University, 3223 North Broad St, Philadelphia, PA 19140 ([email protected]). DOI: 10.1097/PHH.0000000000000102

87 Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

88 ❘ Journal of Public Health Management and Practice Services Task Force (USPSTF), both directly and through “essential health benefits” provisions. In addition, the ACA created an expanded form of Medicaid to provide conditional funding to states that extend and increase health care, including these preventive services, to a broader population.11 The US Supreme Court mandated that this Medicaid expansion must be optional11 —rather than a federal mandate—resulting in variation of coverage across states.12 Ultimately, coverage of preventive care through these different routes depends on the type of health insurance involved and the beneficiary’s state of residence. The strength of preventive services actually provided to recipients will largely depend on how ardently private insurers and state Medicaid offices interpret their mandate under the preventive health requirements. This article reviews the ACA’s requirements related to nongrandfathered private health insurance and Medicaid coverage implicating USPSTF-recommended services for the major risks associated with tobacco use, excessive alcohol consumption, inactivity, and unhealthy diet. The article discusses such services and the need for technical assistance to translate USPSTF recommendations for insurers. The article then examines variations among the ACA’s requirements for private health insurance and Medicaid plans and compares health statuses of populations in states accepting the Medicaid expansion and those declining increased coverage and funds. The article recommends that opt-out states and the federal government increase coverage of clinical preventive services through various legislative mechanisms and concludes with directions for future research.

● The ACA and Preventive Clinical Service Recommendations by the USPSTF There is debate whether investment into clinical preventive services is worthwhile if it does not produce cost savings.9 Commentators have expressed additional concerns over lack of sufficient evidence of benefits, cost-effectiveness, and the feasibility of promoting preventive strategies in routine clinical visits.13 In fact, certain preventive services have both harms and benefits associated with their use, making the decision whether to utilize the service more complex.14 Other preventive services have been shown to be costeffective, meaning that the health benefits outweigh the costs8 or actually provide a net medical cost savings.9,10 The federal government enacted requirements in the ACA for clinical preventive services related to chronic disease stemming from tobacco and alcohol use, unhealthy diet, and inactivity on the basis of the recommendations of the USPSTF.

The USPSTF evaluates existing peer-reviewed studies and makes recommendations on the basis of the strength and quality of the evidence and benefits and harms of the service, as well as additional issues, such as opportunity costs.15 Clinical preventive recommendations are graded “A” or “B” on the basis of the USPSTF’s determination that the service has a substantial or moderate net benefit (hereinafter “recommended services”).15 Although the USPSTF does not explicitly consider financial costs before making a recommendation, it does gather and summarize cost-effectiveness data in its recommendation statement.16 There are 3 entities involved in the USPSTF recommendation process. The USPSTF is an independent panel of experts appointed by the Agency for Healthcare Research and Quality.17 The Agency for Healthcare Research and Quality is a federal agency within the Department of Health and Human Services (DHHS) that provides administrative, research, and technical assistance to the USPSTF and helps disseminate recommendations and implementation materials.17,18 Finally, the National Commission on Prevention Priorities (convened by the Partnership for Prevention) is funded on a project-by-project basis to conduct cost-effectiveness analysis19 and rank USPSTF-recommended services on the basis of their return on investment and the clinically preventable burden of the disease outcome.20 The ACA amended section 2713 of the Public Health Services Act to require certain health plans directly cover the USPSTF-recommended services ranked “A” or “B.”5,21 The USPSTF recommendations targeting adults for the aforementioned identified risk factors include obesity screening and counseling, tobacco use counseling, and interventions for nonpregnant adults, tobacco use counseling for pregnant women, and alcohol misuse screening and counseling.21 Healthy diet counseling is recommended for adults “with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.”21 High blood pressure screening is recommended for all adults,22 and diabetes screening is recommended for adults with elevated blood pressure23 (although both of these recommendations are in the process of being updated).22,23 The USPSTF found that there was insufficient evidence to recommend behavioral counseling to promote physical activity,24 but it is in the process of developing a recommendation for healthy diet and physical activity counseling for at-risk adults.25 There are variations among plans as described later, but ultimately the ability of these requirements to foster prevention will be determined by the extent to which private insurers and states comprehensively implement them for covered persons.

Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Health Care Reform and Clinical Preventive Services

The ACA secondly established a minimum set of benefits that certain plans must cover, called “essential health benefits.”26,27 The Institute of Medicine explained that the goal of essential health benefits is “to cover healthcare needs, to promote services that are medically effective, and to be affordable to purchasers.”28 The ACA requires coverage of 10 categories of essential health benefits to provide core health services, including, among others, hospitalization, maternity and newborn care, prescription drugs, and most notably for this article, “preventive and wellness services and chronic disease management.”26,29 Congress directed DHHS to further define the requirements for essential health benefits within the boundaries of the ACA. For private plans, DHHS’ final regulations of February 2013,30 define “preventive and wellness services and chronic disease management” to include coverage of the USPSTF-recommended services.31,32 Conversely, for Medicaid, only states that accept the Medicaid expansion must include all of the USPSTF “A” and “B” recommendations in their plans. Opt-out states are incented to cover these services through an increase in their federal medical assistance percentage, as discussed later. Despite clear reliance and support for the USPSTF in the ACA and its implementing regulations, there is no clarity with respect to how its recommendations will be practically translated for coverage by insurance companies and states. Although ARHQ might be a potential entity to take on this task, the agency is not politically favored or well-funded.33,34 However, the Partnership for Prevention contains several entities that might have the ability to play this key role. The Partnership convenes the National Commission on Prevention Priorities and also has convened the Health Professionals Roundtable on Preventive Services.35 Furthermore, the Partnership conducted 2 studies prior to the passage of the ACA that examined clinical preventive services in order to help both employers expand coverage36 and states improve mandates.37 The organization appears well-situated to consider translating the current requirements into practice. Another potential method to ensure quality implementation of the clinical preventive service requirements is for insurance accreditation requirements to include coverage of all USPSTF recommendations “A” and “B.” For example, plans are required to be accredited in order to participate in the Health Insurance Exchange Marketplace,38 and these requirements could include comprehensive coverage of the recommended services. Given the ACA’s reliance on the USPSTF and the need for effective clinical preventive services, but acknowledging the political barriers to strengthening preventive systems, Congress’ longer-term goal should be to provide the US infrastructure with consistent fund-

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ing to maintain scientifically robust recommendations and regular updates that include cost-effectiveness analysis, dissemination capabilities, and technical assistance.

● Private Insurance Congress delegated primary responsibility for the regulation of insurance companies to the states,39 but the federal government continues to play a pivotal role through several federal statutes, including the Employee Retirement Income Security Act of 1974. The ACA established federal requirements for increased regulation of private health insurance, but states are responsible for monitoring compliance and enforcement.40 The one exception relevant here is for self-insurance group plans that are exempt from state enforcement through Employee Retirement Income Security Act.41,42 Thus, states may not regulate selfinsurers as insurance companies under Employee Retirement Income Security Act, but all other health insurers remain subject to state control. The ACA requires group health plans and health insurance issuers offering group or individual health insurance to cover all the USPSTF-recommended services without cost sharing.36,43 This applies equally to self-insured group health plans.40,44,45 States may require additional services for the entities under their control and may permit cost sharing for each additional service.40 Thus, all persons with private insurance must have access to the USPSTF recommendations rated “A” and “B.” It is noteworthy that large group health plans and self-insured group plans are explicitly excluded from the requirement to cover essential health benefits42 ; however, they must still cover the USPSTFrecommended services pursuant to section 2713 of the Public Health Services Act.5,40 States can choose to increase regulation for large group health plans to require coverage of essential health benefits,46 but states cannot do the same for self-insured plans.37 This is one of several exceptions in the ACA for self-insured plans. Historically, only large employers utilized selfinsurance because of the cost of providing such plans, but in light of ACA exemptions,47 attorneys are pursuing methods for smaller employers to follow suit.48 There is a concern that the ACA will encourage employers to self-insure in order to offer employees “barebones health plans” within the confines of the law.49,50 In this case, employees might exercise their option to purchase insurance from an exchange to obtain more comprehensive coverage, giving rise to additional issues such as increased costs for outside insurers and penalties for employers.51

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90 ❘ Journal of Public Health Management and Practice

● Medicaid

● Medicaid Expansion

Medicaid is a federal-state cooperative health insurance program, but Congress sought to grant states flexibility to tailor plans to their needs, so coverage for adults is highly dependent on state prerogatives.11 Historically, states provided traditional state Medicaid plans. In 2005, Congress established benchmark benefit plans as a method to allow states to provide a more narrow set of coverage.52 Customarily, these were less comprehensive than traditional Medicaid plans, but this is no longer the case since the ACA’s enactment. Now, if a state opts for expanded Medicaid coverage through the ACA, the newly eligible individuals must be enrolled in the benchmark or benchmarkequivalent plans. However, the ACA amended these plans, changed the name to Alternative Benefit Plans,53 and expanded coverage so that Alternative Benefit Plans must now cover the 10 categories of essential health benefits.31,53 As discussed previously, this includes USPSTF-recommended services “A” and “B.”30,31,53 Therefore, recipients obtaining coverage through the Medicaid expansion must have access to these services.54 For states maintaining traditional Medicaid plans, however, the USPSTF-recommended services remain optional,55 with the exception of mandatory tobacco cessation therapy for pregnant women.56,57 As a result, in states not expanding Medicaid, this leaves a substantial gap in coverage. In states declining to expand Medicaid, low-income working-age adults without dependent children are the group most likely to be left without health insurance.58 Many of the USPSTF adult clinical preventive service recommendations are geared toward this population.21 In a nationally representative study of 1042 low-income working-age adults potentially eligible to enroll in Medicaid under the expansion, Decker et al59 found that if they had hypertension, hypercholesterolemia, or diabetes, a substantial portion of these adults had undiagnosed or untreated diseases. Furthermore, low-income uninsured adults were almost twice as likely to use an emergency department for their usual source of care.59 The ACA offers a 1-point increase in a state’s federal medical assistance percentage for the cost of providing USPSTF-recommended services to adults.54,60 Medicaid beneficiaries in states with traditional Medicaid plans will have less coverage for preventive services than new enrollees and beneficiaries in states with Alternative Benefit Plans if the state does not accept this incentive.12 While it is accurate that a state’s coverage of a USPSTF recommendation does not guarantee comprehensive or similar services across states,61 Medicaid recipients in states that do not cover these preventive services are at a disadvantage.

As of March 2014, 26 states and the District of Columbia are moving forward with the Medicaid expansion, while 19 states have opted out and 5 are still debating the issue.62 Several states have proposed alternatives to the expansion.63 For example, the Centers for Medicare & Medicaid Services approved applications from Arkansas and Iowa for a waiver to implement the expansion by using Medicaid funds as premium assistance to purchase coverage for newly eligible Medicaid beneficiaries.64 States’ decisions whether to accept expansion funds to provide expanded coverage have generally fallen along party lines.65 Political maneuvering and state-initiated litigation against DHHS11 have largely clouded the important practical considerations that should factor into this decision.66 First, states should expect to realize positive health outcomes by expanding Medicaid coverage and potential health losses by opting out. In a natural experiment comparing states that expanded services prior to the ACA with neighboring states that did not, Medicaid expansion was associated with, among other benefits, a significant reduction in adjusted all-cause mortality, increased self-report of excellent or very good health, and a decreased rate of delayed care due to cost barriers.67 Conversely, researchers from the City University of New York and Harvard Medical School quantified the number of deaths that will be attributable to the lack of Medicaid expansion in opt-out states as between 7115 and 17 104, annually.68 These estimates are based on populations without health insurance in opt-out states, who as a result of the opt-out would not gain access to necessary and lifesaving preventive services, screenings, and medications. Second, the federal government will finance a greater proportion of the new Alternative Benefit Plans than the traditional Medicaid state plans for at least several years. For traditional plans, the federal government pays 50% to 83% of the costs of covering individuals currently enrolled in Medicaid.55 Conversely, the federal government pays 100% of the newly eligible persons’ coverage under the Medicaid expansion, which will incrementally be phased downward to 90% in 2020.69 The Congressional Budget Office reported that the actual additional cost to states will be only 2.8% more than what states would have spent on Medicaid in the absence of health reform, and this figure does not reflect the potential savings that state and local governments will realize for the formerly uninsured.70 Third, residents in opt-out states seem to need increased access to health services. The Table 1 compares states taking the Medicaid expansion with states

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Health Care Reform and Clinical Preventive Services

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TABLE ● Comparing States Taking the Medicaid Expansiona With States Opting Out of the Medicaid Expansionb on 6 Health

Indicators qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Variables Life expectancyd

Diabetesf

Heart diseasesg

h

Smoking

Obesity

i

Physical activity

j

Group

Meanc

Expansion Opt-out Diff (1-2) Expansion Opt-out Diff (1-2) Expansion Opt-out Diff (1-2) Expansion Opt-out Diff (1-2) Expansion Opt-out Diff (1-2) Expansion Opt-out Diff (1-2)

79.6315 78.0623 1.5692 0.0958 0.1064 − 0.0106 173.0 185.7 − 12.7835 0.1744 0.2058 − 0.0315 0.6207 0.6505 − 0.0298 0.5395 0.4897 0.0498

95% CI Mean 79.0830 77.5119 0.8072 0.0893 0.1018 − 0.0183 163.1 175.6 − 26.5993 0.1581 0.1953 − 0.0505 0.6096 0.6428 − 0.0430 0.5238 0.4708 0.0261

80.1800 78.6126 2.3313 0.1023 0.1110 − 0.00281 182.8 195.9 1.0324 0.1907 0.2164 − 0.0124 0.6318 0.6582 − 0.0166 0.5552 0.5085 0.0736

df

P > |t|

t

49

4.14

.0001e

45.513

− 2.74

.0087e

49

− 1.86

.0490e

43.59

− 3.33

.0018e

45.071

− 4.55

The affordable care act and state coverage of clinical preventive health services for working-age adults.

Significant public health challenges facing the United States stem from preventable disease. The Patient Protection and Affordable Care Act dedicated ...
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