Geiger Gibson Program in Community Health
Policy Issue Brief #71
June 2023
Updated September 19,2023+
Caitlin Murphy, MPA
Rebecca Morris, MPP
Kay Johnson, MEd, MPH
Sara Rosenbaum, JD
- Background
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Braidwood Management v Becerra, now pending before the United States Court of Appeals for the Fifth Circuit, challenges the constitutionality of Section 2713 of the Affordable Care Act. Section 2713 guarantees nearly all privately insured Americans coverage for comprehensive, lifesaving preventive benefits without cost-sharing across the lifespan, from pregnancy and birth to old age.1 Except for privately insured Americans covered under a grandfathered health plan (approximately 13 percent),2 the preventive benefit guarantee applies to all forms of private insurance, including individual policies, small and large group insurance plans, and plans offered by employers that self-insure. In 2021, an estimated 150 million privately insured people were covered under a plan subject to Section 2713.3 Comprehensive preventive benefits are a part of all qualified health plans sold in the health insurance marketplace, as well as health plans insuring people covered through the ACA Medicaid expansion.
The preventive benefit guarantee is extremely important to community health centers and safety net providers given the patients they serve. The broad scope of the guarantee not only ensures financing for preventive care but also better enables appropriate patient care management.
The trial court decision in Braidwood focused on the constitutionality of the United States Preventive Services Task Force (USPSTF). However, it is possible that on appeal, the Braidwood challengers will claim that all four categories of Section 2713 benefits are unconstitutional and will argue that any preventive benefit added post-ACA enactment (March 23 2010) cannot be enforced. This argument thus would call into question not only USPSTF recommendations but also recommendations pertaining to immunizations, women’s health, and child health.
In this policy brief we assess the potential impact of this global challenge to preventive care on patient and population health, focusing on maternal and child health.
- Key Findings
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The importance of focusing on maternal and child health
No population better illustrates the significance of Section 2713 than women, infants, and children. Together, the four preventive benefit categories included in Section 2713 include scores of services universally identified by public health experts as foundational to promoting healthy maternal and child health outcomes. The benefits are especially important for women and children with low family incomes who, as extensive research shows, can face nearly insurmountable barriers to effective care.4
The U.S. faces major maternal and infant health challenges
The Centers for Disease Control and Prevention (CDC) reports that in 2020, the US infant mortality rate stood at 5.4 deaths per 1000 live births,5 a rate that exceeds those found in other high-income nations.6 The US also has long experienced elevated maternal mortality linked to complications of pregnancy and childbirth. In 2021, 1,205 women died of maternal causes in the United States compared to 861 in 2020, and 754 in 2019.7 The maternal mortality rate for 2021 stood at 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019.8 The U.S. maternal mortality rate was almost triple the rate found in other high-income countries.9
Numerous factors drive maternal mortality and other deaths classified as pregnancy-related:10 poor health entering pregnancy, inadequate prenatal care that fails to identify and address conditions that could complicate pregnancy such as high blood pressure or gestational diabetes, and insufficient postpartum care to rapidly detect and address conditions that could lead to death and lifelong disability following birth.11 Maternal mortality and disability are associated with lower family income, which is associated with more limited use of health care overall.12
Similarly, infant mortality rates, along with associated rates of birth complications leading to long term disability, are driven by multiple factors, chief among which are preterm and low birthweight, combined with insufficient care for mothers before, during, and after pregnancy.13
The effectiveness of preventive health care prior to, during, and following pregnancy and the role of Section 2713
Accessible preventive care has been recognized as essential to maternal and infant health, as recognized by the CDC, the Institute of Medicine, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, and numerous other clinical expert bodies.14, 15, 16, 17, 18
Research has established that preventive care during the preconception, prenatal, and postpartum period vastly improves maternal, infant, and family health - including screenings for anxiety and depression, gestational diabetes, HIV and sexually transmitted infections (STIs), cervical cancer, breast cancer, and domestic violence, vaccines such as those for HPV, influenza, and COVID-19, and interventions such as those that support breastfeeding and prevent unintended pregnancy, obesity, STIs, and more.19, 20, 21, 22, 23, 24, 25, 26, 27 All of these services are currently provided without cost-sharing as part of one or more of the Section 2713 benefit categories. Many of these services are widely used and regularly provided at standard visits for well-women, prenatal care, and postpartum care. Receipt of enhanced prenatal care, which includes many procedures included in Section 2713, is associated with fewer emergency visits, less likelihood of preterm birth and low birthweight deliveries, and greater likelihood of attendance at well-visits. 28, 29, 30 However, the research has shown that receipt of these services will be reduced if cost-sharing is introduced.
The Kaiser Family Foundation (KFF) estimates that 60% of the privately insured population receive at least one preventive service annually. KFF data also show that three-quarters of women had received a well-woman visit or general “check-up” visit in the past two years.31
The impact of inadequate access to care
Inaccessible preconception, prenatal, and postpartum preventive services can be life-threatening and even deadly. For example, evidence from the CDC shows that the nation is currently experiencing an STI/STD epidemic resulting in increased infant mortality.32, 33, 34 A 235% increase in congenital syphilis has contributed to at least 149 still births and infant deaths in 2020 and 166 infant deaths in 2021.35 These conditions are treatable before and during pregnancy, but first require accessible screening.36
Gestational diabetes has been shown to affect up to 10% of pregnant women, and the US has experienced a 30% jump in the gestational diabetes rate over the past decade.37, 38 Untreated gestational diabetes is associated with an eight-fold increase in preeclampsia, a leading cause of maternal and infant mortality, as well as increases the likelihood of pregnancy-associated hypertension, preterm birth, the incidence of childbirth injuries, and stillbirth.39, 40 Inaccessible screening will increase the likelihood of these outcomes.
Mental health disorders are the leading complication in pregnancy, affecting 20 percent of all pregnancies.41 Untreated mental health disorders are also a leading cause of maternal mortality.42 Mental health screening during pregnancy, one of the preventive benefits guaranteed under Section 2713 (included in the USPSTF and Bright Futures preventive service bundles), are critical to detecting and treating mental health problems in pregnancy.
Moreover, entering pregnancy in good health is central to ensuring healthy pregnancies and births. The services guaranteed by Section 2713 go directly to preconception health, that is, health leading into pregnancy. These services include well-woman visits, which are covered without cost-sharing as part of the WPSI preventive services bundle. Well-woman visits typically include cervical cancer screening (which can prevent 4,000 deaths annually), breast cancer screening (which saves 3,700 lives if 90% of women are screened), and contraceptive counseling.43, 44 Planned pregnancy is crucial to healthy pregnancy; for this reason, access to effective birth control is essential to maternal and infant health.45 Unintended pregnancy is significantly associated with worse maternal and infant health outcomes, such as preterm birth, low birth weight, poor mental health, and interpersonal violence.46
The impact of eliminating cost as a barrier to health care
Lack of affordable care has repeatedly been shown to reduce the use of preconception, pregnancy, and postpartum preventive services, while eliminating cost-sharing has been shown to increase use of care. Pre-ACA studies documented the negative impact of cost-sharing on use of preventive care prior to and during pregnancy. These studies showed that pre-ACA implementation, 20% of all women, 13% of insured women, and 35% of women living in a household earning <200% FPL put off preventive services in the past year due to cost.47 Numerous studies have shown that women are significantly less likely to receive preventive services such as mammograms and pap smears when cost-sharing is required.48, 49
Following ACA implementation, research documented the positive impact of eliminating cost-sharing on use of preventive services.50 For example, breastfeeding support is a major preventive benefit secured by the ACA women’s health benefit. Following implementation, research showed an eleven-fold increase in claims associated with use of breast pumps among women with private insurance, a crucial benefit associated with increased breastfeeding rates,51 leading to an estimated 47,000-infant increase in breastfeeding.52 Rates of HIV and STI screenings also increased following ACA implementation,53, 54 as did mammography rates and associated preventive counseling, particularly for low-income women.55
Eliminating the free preventive care secured by Section 2713 could have a major impact on maternal and child health
Across all four coverage categories protected by Section 2713 (women’s health services, child health services,56 immunizations, and preventive services identified by the USPSTF) there are a total of 193 distinct screening and treatment procedures. Among these, 125 services (two-thirds of all covered procedures) are directly relevant to maternal and infant health. Also, within the 193 procedures are 55 procedures (28 percent of all covered procedures) that focus specifically on children and adolescents.
In Braidwood, plaintiffs challenge the legality of procedures adopted post-ACA enactment in 2010. Eliminating these post-enactment procedures would have a major adverse impact on coverage. At stake are not only the brand-new procedures added since 2010, but also, presumably, changes that have expanded the range of elements included in a procedure, or changes that expand the populations entitled to certain procedures:
Of the 193 preventive services now covered, only 48 (25 percent) remain fully intact.
- A total of 122 recommended procedures would be eliminated in their entirety. Examples of services that would be eliminated from ACA protections include: lung cancer screening, colorectal cancer screening for adults 45-49, counseling and provision of the full range of contraception methods, breast cancer and skin cancer prevention services, obesity prevention services, type 2 diabetes screening, anxiety screening, statin use for prevention of cardiovascular disease, screening for unhealthy drug use, STI prevention services, and Hepatitis C screening.
- Additionally, in the case of 13 procedures, coverage would be eliminated for key populations of children and adults who were added to the coverage recommendations.57 For example, HIV testing would be eliminated for “low risk” youth and adults, alcohol use screening and Hepatitis B screening would be eliminated for adolescents, and depression screening for youth and adults would be eliminated for anyone in a care setting that does not have “staff-assisted depression care supports”.58
- Furthermore, 10 recommended procedures would lose essential post-2010 modifications aimed at making them more effective.59 For example, new approaches to colorectal cancer screening and hypertension screening were recommended post-2010, and these strategies would be lost if the Fifth Circuit upheld Braidwood’s coverage challenge.
Among the 125 covered procedures directly relevant to maternal and infant health, only 29 would be maintained in full. Of the procedures, 90 would be eliminated, five would lose key populations, and one would lose essential post-2010 modifications.
- Among the services that would be lost is the federal Recommended Uniform Screening Panel (RUSP) for newborns, established after enactment of the ACA, which established a national, uniform set of newborn screening procedures and ensured coverage for all infants. Also lost would be hearing screening, blood tests, and screening for hereditary disorders (such as cystic fibrosis and severe immunodeficiencies). Other infant services that would be eliminated include: key immunizations (such as the Respiratory Syncytial Virus (RSV) vaccine, COVID-19 vaccine, and DTaP-IPV-Hib-HepB vaccine), fluoride varnish (once teeth erupt), behavioral screening, and blood pressure measurements.
- For mothers, examples of the preventive services that would be eliminated include: gestational diabetes screening, diabetes mellitus screening after pregnancy, preeclampsia screening, maternal depression and intimate partner violence screening, screening for unhealthy drug and alcohol use in pregnancy, and key immunizations such as the Respiratory Syncytial Virus (RSV) vaccine and the COVID-19 vaccine
Among the 55 procedures directly relevant to children and adolescents, only 24 would be maintained in full, 24 would be lost, five would lose key populations, and two would lose essential post-2010 modifications.
- Among the procedures lost for children and adolescents are screening for anxiety, behavioral screenings, prevention services for alcohol, tobacco, and drug usage, cardiovascular risk reduction services, universal cholesterol screenings, Hepatitis C screenings, provision of fluoride varnish, and key immunizations such as COVID-19.
- Five procedures would be modified to eliminate key populations; for example, HIV screens and Hepatitis B screens would be eliminated “low risk” youth and the Meningococcal vaccine would be eliminated for adolescents. Moreover, essential post-2010 modifications would be lost regarding hypertension screening for youth and the provision of the Varicella vaccine.
- Concluding Thoughts
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The Affordable Care Act’s free preventive benefit guarantee has benefitted nearly all privately insured Americans, as well as millions of ACA Medicaid expansion beneficiaries. No populations have benefitted more from these reforms than women, infants, and children. Braidwood could take these gains away.
Maternal and child health stand as one of the most basic measures of overall population health, and in this regard, the ACA has profoundly changed the health care landscape by newly insuring tens of millions of people and broadening the coverage to which they are entitled. Eliminating free preventive coverage would reverse these gains, with long-term implications for maternal and child health.
+ Updated September 19, 2023 to incorporate Respiratory Syncytial Virus (RSV) vaccine
Download Table of ACA Preventative Services Protected or Eliminated under Braidwood
