71. Braidwood Management v Becerra Could Eliminate Three Quarters of the Affordable Care Act’s Preventive Benefits for Women, Infants, and Children

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

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

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

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

• 1These preventive services include those rated “A” or “B” by the United States Preventive Services Taskforce (USPSTF), as well as those included in the Women’s Preventive Services Initiative (WPSI) bundle, the Bright Futures recommendations, and the Advisory Committee on Immunization Practices (ACIP) bundle.
• 2Kaiser Family Foundation. (2019) Employer Benefits Survey. https://www.kff.org/report-section/ehbs-2019-section-13-grandfathered-health-plans/#:~:text=Thirteen%20percent%20of%20covered%20workers,16%25)%20%5BFigure%2013.3%5D.
• 3United States Department of Health and Human Services (2022). Access to Preventive Services without Cost-Sharing: Evidence from the Affordable Care Act. https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf
• 4United States Department of Health and Human Services. (nd). Healthy People 2030. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/poverty
• 5CDC (2022). Infant Mortality. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
• 6The Commonwealth Fund. (2023). US Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022
• 7Hoyert DL. Maternal mortality rates in the United States, 2021. NCHS Health E-Stats. 2023. DOI: https://dx.doi.org/10.15620/cdc:124678 
• 8Hoyert DL. Maternal mortality rates in the United States, 2021. NCHS Health E-Stats. 2023. DOI: https://dx.doi.org/10.15620/cdc:124678
• 9CDC. (2023). Maternal Mortality Rates in the US, 2021. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.pdf
• 10Note: Maternal mortality is defined as death during pregnancy or 42 days after the end of pregnancy.  A pregnancy-related death may occur during pregnancy or within one year of the end of pregnancy from related causes. See: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm and https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html.
• 11The Commonwealth Fund. (2020). Maternal Mortality in the US: A Primer. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer
• 12The Commonwealth Fund. (2018). Why Even Healthy Low-Income People Have Greater Health Risks than Higher-Income People.  https://www.commonwealthfund.org/blog/2018/healthy-low-income-people-greater-health-risks
• 13CDC. (2022). Infant Mortality. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
• 14American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 313, September 2005. The importance of preconception care in the continuum of women's health care. Obstetrics and Gynecology. 2005;106(3): 665–666. https://doi.org/10.1097/00006250-200509000-00052
• 15Institute of Medicine. (2011). Clinical Preventive Services for Women: Closing the Gaps. The National Academies Press. https://doi.org/10.17226/13181
• 16Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Curtis MG. Recommendations to improve preconception health and Health Care—United States: Report of the CDC/ATSDR preconception care work group and the select panel on preconception care. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2006;55(RR 6): 1-23. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm
• 17American Academy of Family Physicians. (2016). Preconception care: Position Paper. https://www.aafp.org/about/policies/all/preconception-care.html  
• 18American College of Obstetricians and Gynecologists.  (2017). Guidelines for Perinatal Care: Eighth Edition. https://www.acog.org/clinical-information/physician-faqs/-/media/3a22e153b67446a6b31fb051e469187c.ashx
• 19Atrash H, Jack B. Preconception care to improve pregnancy outcomes: The science. J Hum Growth Dev. 2020;30(03):355–362. https://doi.org/10.7322/jhgd.v30.11064
• 20Jack BW, Atrash H, Coonrod DV, Moos MK, O'Donnell J, Johnson K.  The clinical content of preconception care: an overview and preparation of this supplement. American Journal of Obstetrics and Gynecology. 2008;199(6): S266-S279. [See full supplement for recommendations.] https://doi.org/10.1016/j.ajog.2008.07.067. 
• 21Frayne DJ, Verbiest S, Chelmow D, Clarke H, Dunlop A, Hosmer J, ... & Zephyrin L. . Health care system measures to advance preconception wellness: Consensus recommendations of the clinical workgroup of the National Preconception Health and Health Care Initiative. Obstetrics & Gynecology. 2016;127(5): 863-872. https://doi.org/10.1097/AOG.0000000000001379 
• 22Dorney E, Boyle JA, Walker R, Hammarberg K, Musgrave L, Schoenaker D, Jack B, Black KI. A Systematic Review of Clinical Guidelines for Preconception Care. Semin Reprod Med. 2022;40: 157-169 https://doi.org/10.1055/s-0042-1748190.
• 23Zaçe, D, Orfino, A, Mariaviteritti, A, Versace, V, Ricciardi, W, DI Pietro, ML.  A comprehensive assessment of preconception health needs and interventions regarding women of childbearing age: a systematic review. J Prev Med Hyg. 2022;63(1):E174-E199. https://doi.org/10.15167/2421-4248/jpmh2022.63.1.2391
• 24Moos, MK, Dunlop, AL, Jack, BW, Nelson, L, Coonrod, DV, Long, R, Boggess, K, Gardiner, PM. (2008). Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age. Am J Obstet Gynecol. 199(Suppl. 2):S280-9. https://doi.org/10.1016/j.ajog.2008.08.06010.1016/j.ajog.2008.08.060
• 25Institute of MedicineCommittee to Study Outreach for Prenatal Care, & Brown SS. . Prenatal Care: Reaching Mothers, Reaching Infants. National Academies Press. 1988. https://doi.org/10.17226/731
• 26Rosen MG, Merkatz IR, Hill JG.  Caring for our future: a report by the expert panel on the content of prenatal care. Obstetrics and Gynecology. 1991;77(5): 782–787. https://pubmed.ncbi.nlm.nih.gov/2014096/
• 27Handler, A., Johnson, K. A Call to Revisit the Prenatal Period as a Focus for Action Within the Reproductive and Perinatal Care Continuum. Matern Child Health J 20, 2217–2227 (2016). https://doi.org/10.1007/s10995-016-2187-6
• 28Cogan LW, Josberger RE, Gesten FC, Roohan PJ. Can prenatal care impact future well-child visits? The experience of a low income population in New York State Medicaid managed care. Matern Child Health J. 2012;16(1):92-9. https://doi.org/10.1007/s10995-010-0710-8 
• 29Roman L, Raffo JE, Zhu Q, Meghea CI. A statewide Medicaid enhanced prenatal care program: impact on birth outcomes. JAMA Pediatr. 2014;168(3):220-7. https://doi.org/10.1001/jamapediatrics.2013.4347
• 30Roman LA, Raffo JE, Strutz KL, Luo Z, Johnson ME, Meulen PV, Henning S, Baker D, Titcombe C, Meghea CI. The Impact of a Population-Based System of Care Intervention on Enhanced Prenatal Care and Service Utilization Among Medicaid- Insured Pregnant Women. Am J Prev Med. 2022 Feb;62(2):e117-e127. https://doi.org/10.1016/j.amepre.2021.08.012 
• 31Kaiser Family Foundation. (2021). Women’s Health Care Utilization and Costs: Findings from the 2020 KFF Women’s Health Survey. https://www.kff.org/womens-health-policy/issue-brief/womens-health-care-utilization-and-costs-findings-from-the-2020-kff-womens-health-survey/ 
• 32National Center for Health Statistics. Health US 2020-2021: Table: Selected nationally notifiable disease rates and number of new cases: United States, selected years 1950–2019. CDC. 2021.  https://www.cdc.gov/nchs/data/hus/2020-2021/idnotif.pdf
• 33Kreisel et al.  2018 Sexually Transmitted Infections Among US Women and Men: Prevalence and Incidence Estimates. Sexually Transmitted Diseases: 2021;48(4), 208-214. https://journals.lww.com/stdjournal/Fulltext/2021/04000/Sexually_Transmitted_Infections_Among_US_Women_and.2.aspx
• 34CDC. (2022). New Data Shows that STDs Remain Far Too High. https://www.cdc.gov/std/statistics/2020/default.htm 
• 35Kaiser Health News. (2022). Babies Die as Congenital Syphilis Continues a Decade-Long Surge Across the US. https://khn.org/news/article/babies-die-as-congenital-syphilis-continues-a-decade-long-surge-across-the-us 
• 36CDC. (2023) Congential Syphilis: Factsheet. https://www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm#:~:text=What%20is%20congenital%20syphilis%20(CS,Learn%20more%20about%20syphilis.
• 37CDC (2022). Gestational Diabetes. https://www.cdc.gov/diabetes/basics/gestational.html#:~:text=Gestational%20diabetes%20is%20a%20type,pregnancy%20and%20a%20healthy%20baby
• 38Shah NS, Wang MC, Freaney PM, et al. Trends in Gestational Diabetes at First Live Birth by Race and Ethnicity in the US, 2011-2019. JAMA. 2021;326(7):660–669. https://doi.org/10.1001/jama.2021.7217
• 39Domanski, G., Lange, A.E., Ittermann, T. et al. Evaluation of neonatal and maternal morbidity in mothers with gestational diabetes: a population-based study. BMC Pregnancy Childbirth 2019;18(1):367. doi.org/10.1186/s12884-018-2005-9. https://doi.org/10.1186/s12884-018-2005-9
• 40March of Dimes. (2022). Gestational Diabetes. https://www.marchofdimes.org/find-support/topics/pregnancy/gestational-diabetes
• 41Chen J, Cox S, Kuklina EV, Ferre C, Barfield W, Li R. Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US. JAMA Netw Open. 2021;4(2):e2036148. https://doi.org/10.1001/jamanetworkopen.2020.36148
• 42Trost SL, Beauregard J, Njie F, et al.  (2022). Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. Centers for Disease Control and Prevention, US Department of Health and Human Services https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html?source=email
• 43National Commission on Prevention Priorities. (2007). Preventive Care: A National Profile on Use, Disparities, and Health Benefits. Washington, DC: National Commission on Prevention Priorities.
• 44CDC. (2022). Cervical Cancer Statistics. https://www.cdc.gov/cancer/cervical/statistics/index.htm
• 45American College of OB-GYNs (2022.) Access to Contraception. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/01/access-to-contraception
• 46Nelson HD, Darney BG, Ahrens K, et al. Associations of Unintended Pregnancy With Maternal and Infant Health Outcomes: A Systematic Review and Meta-analysis. JAMA. 2022;328(17):1714–1729. https://doi.org/10.1001/jama.2022.19097
• 47Kaiser Family Foundation. (2015). Preventive Services Covered by Private Health Plans Under the ACA. https://files.kff.org/attachment/preventive-services-covered-by-private-health-plans-under-the-affordable-care-act-fact-sheet
• 48Solanki G, Schauffler HH. Cost-sharing and the utilization of clinical preventive services. Am J Prev Med. 1999;17(2):127-33. doi: 10.1016/s0749-3797(99)00057-4.  https://pubmed.ncbi.nlm.nih.gov/10490055/  
• 49Lurie, N., Manning, W. G., Peterson, C., Goldberg, G. A., Phelps, C. A., & Lillard, L. (1987). Preventive care: do we practice what we preach? American journal of public health, 77(7), 801–804. https://doi.org/10.2105/ajph.77.7.801
• 50Norris HC, Richardson HM, Benoit M-AC, Shrosbree B, Smith JE, Fendrick AM. Utilization Impact of Cost-Sharing Elimination for Preventive Care Services: A Rapid Review. Medical Care Research and Review. 2022;79(2):175-197. . https://doi.org/10.1177/10775587211027372  
• 51Hawkins, S. S., Noble, A., & Baum, C. F. (2017). Effect of the Affordable Care Act on Disparities in Breastfeeding: The Case of Maine. American Journal of Public Health, 107(7), 1119–1121. https://doi.org/10.2105/AJPH.2017.303763
• 52K Kapinos, K. A., Bullinger, L., & Gurley-Calvez, T. (2017). Lactation Support Services and Breastfeeding Initiation: Evidence from the Affordable Care Act. Health Services Research, 52(6), 2175–2196. https://doi.org/10.1111/1475-6773.12598
• 53Analysis of 2016-2022 claims data by FAIRHealth.
• 54Analysis of 2016-2022 claims data by FAIRHealth.
• 55Lee LK, Monuteaux MC, Galbraith AA.  Women's Affordability, Access, and Preventive Care After the Affordable Care Act. American journal of preventive medicine, 2019;56(5), 631–638. https://doi.org/10.1016/j.amepre.2018.11.028
• 56This includes child health includes services in the Bright Futures schedule and the Recommended Uniform Screening Panel (RUSP) approved by HHS for newborn screening of hereditary disorders. Conditions listed on the RUSP are part of the comprehensive preventive health guidelines for infants and children under section 2713 of the Public Health Service Act.  https://www.hrsa.gov/advisory-committees/heritable-disorders/rusp
• 57For the following services, coverage for key populations would be lost: gonorrhea screening (“low risk” women under 24), chlamydia screening (“low risk” women 25 and older), Hepatitis B screening (“low risk” adolescents), depression screening (youth and adults in care settings that don’t have “staff-assisted depression care supports”), alcohol use screening (adolescents), HIV screening (adolescents and adults at “low risk”), high-risk cardiovascular behavioral counseling (adults who don’t have hyperlipidemia), Meningococcal vaccines (adolescents), HPV vaccines (males 22-26 years old), and Hep B vaccines (“low risk” individuals 19-59 years old).
• 58USPSTF Depression Screening for Adults: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/depression-in-adults-screening; USPSTF Depression Screening for Children and Adolescents: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-children-adolescents 
• 59For the following services, essential post-2010 elements would be eliminated: BRCA screening, cervical cancer screening, colorectal cancer screening for adults 50-75, hypertension screening, tobacco cessation services, osteoporosis screening for women under 65 with increased risk, and the Anthrax, Varicella, and Rabies vaccines.