What happens when preventive care becomes free to patients? New review takes a look

This article was updated on March 30, 2023: A judge in Texas has ruled in the court case mentioned in this article, Braidwood v. Becerra. The judge ruled against the Affordable Care Act's provisions that certain types of preventive care should be free to patients. The ruling affects care that is recommended by the U.S. Preventive Services Task Force, including many types of care discussed in this article.

This note will be updated with information on the status of any stay, appeal or other action related to this ruling.

When most Americans go to get a mammogram, a colonoscopy, a vaccine, a blood pressure check or birth control, they may not realize that the Affordable Care Act is likely the reason they don’t have to pay anything for that service.

But are more people seeking those services because of the ACA’s mandate that most insurance plans cover certain preventive services with no co-pays or deductibles?

And what might happen if the federal courts strike down that clause, in a case called Kelley v. Becerra?

A new review of past studies on this topic – many dating before the ACA, when some insurers made certain preventive services available for no cost – takes a look. 

Based on the evidence to date, the authors from the University of Michigan Center for Value-Based Insurance Design conclude the majority of studies show an increase in patients getting these key services, though the picture is complicated by changes in recommendations about exactly who should get those services. They note that more research is needed on how the use of 68 preventive services on the current cost sharing exempt list was impacted by the ACA provision.

People who have the largest financial barriers to care saw the largest gains, at least in the subset of studies that included data about subgroups of patients. This includes those with low incomes, Medicare participants without supplemental insurance, and those who faced high costs for a service before the cost was eliminated.

“The impact of cost-sharing elimination varied depending on the clinical service, with a majority of studies examined showing increases in use,” says A. Mark Fendrick, M.D., who directs the center and is a professor of medicine at the U-M Medical School and primary care physician at U-M Health. “Our findings suggest that low-socioeconomic status groups, and those who experience the greatest financial barriers to care, appear to benefit the most from cost-sharing elimination.”

The review was led by V-BID Center research associates Hope Norris, Haley Richardson, Marie-Anais Benoit and Beth Shrosbree.

Published in the journal Medical Care Research and Review, the review analyzes 35 original studies on 10 high-value preventive services recommended by official national panels of experts. No studies on the other 58 services were found or met the criteria for inclusion.

To avoid having to pay co-pays or deductibles under the ACA, a patient must be eligible for a particular screening, immunization, test, medication or counseling under the recommendations of the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices or the Health Resources and Services Administration. 

Those recommendations can change over time as more evidence about the impact of a service for a particular group is gathered, as was the case for breast and cervical cancer screening during the years covered by studies in the review. COVID-19 testing and vaccination have also been deemed to meet the ACA mandate’s requirements and are available at no cost to anyone in the U.S.

“We and others advised on the section of the ACA, on Medicare Advantage demonstration projects, and on other programs that aim to reduce financial barriers to high-value preventive care, working with both Congressional Republicans and Democrats,” Fendrick said. “Now that the fate of the entire Affordable Care Act has likely been decided in the recent Supreme Court decision, our findings indicate that any potential removal of its provision to eliminate patient costs for preventive care could have negative implications, especially for those who are financially vulnerable.” 

Key findings from the review: 

Breast cancer screening: Half of the studies identified by the review’s authors addressed this type of preventive care, and nearly half concluded that reduction in cost sharing led to increases in use. African-Americans, and Medicare beneficiaries who don’t have supplemental insurance, saw larger increases.

But interpretation of the impact of cost-sharing elimination is complicated by the fact that in 2009, the USPSTF changed its recommendations to increase the time between mammograms for women between the ages of 50 and 74, and to recommend against screening among women over 75. The authors also note that many insurers made screening mammograms free to patients even before the ACA.

Cervical cancer screening: Five studies have looked at the impact of making Pap smears and other tests available for no cost, and they show a modest effect. But as with breast cancer screening, a change in recommendation by the USPSTF that women over 30 should get tested every three years instead of every year complicates the ability to see an impact. 

Colon cancer screening: Eliminating cost-sharing for colonoscopy and other exams was only found to lead to increases in screening in three studies. But the authors note that researchers conclude that lost wages, embarrassment or discomfort at the invasive nature of colonoscopy, and fear of complications may be larger barriers than cost. Awareness of the lack of cost for this infrequent test may also contribute.  

Contraception and sterilization: This form of care has the strongest evidence for the impact of cost-sharing eliminations on use by patients, the study concludes. Both long-acting reversible contraception using implants, and short-term methods such as pills and patches, saw increases. But increases were larger for the long-acting forms, especially among groups of women who had the largest declines in out-of-pocket costs after the mandate took effect. 

Other services: The authors looked at the available small numbers of studies of tobacco cessation, immunization, cholesterol and blood pressure checks, genetic testing for breast cancer risk linked to the BRCA gene, and weight loss counseling. 

Cost-sharing elimination was linked to increases in use of prescription nicotine patches and gums, immunizations especially among young children, cholesterol and blood pressure measurements, BRCA testing and weight counseling. However, more research is needed on trends in the use of these and other high-value services, the researchers say.