A new report from researchers at the George Washington University Milken Institute School of Public Health presents the most detailed evidence to date regarding the potential effects on mothers and children of Braidwood Management v. Becerra, which challenges the constitutionality of the Affordable Care Act’s comprehensive free preventive benefit guarantee for nearly all privately insured people.
Also affected could be people insured through the act’s Medicaid expansion for low-income working-age adults. Some 150 million privately insured people as well as 20 million Medicaid beneficiaries could be affected. The report also notes the potential effects on health care providers, such as community health centers, that treat the nation’s most vulnerable and low-income populations.
In March, a federal judge invalidated the ACA’s mandate for private insurers to cover certain kinds of preventive screenings and care. In May, the United States Court of Appeals for the Fifth Circuit issued an administrative stay on that judge’s decision. The Fifth Circuit is expected to release a final judgment on the government’s appeal later this year.
“Maternal and child health is one of the most sensitive indicators of a nation’s health,” Milken Institute SPH Dean Lynn R. Goldman said. “At a time when the nation’s maternal and infant mortality rates vastly exceed those of other wealthy nations, it is simply unthinkable that this amount of affordable coverage would be lost.”
The report, “Braidwood Management v Becerra Could Eliminate Three Quarters of the Affordable Care Act’s Preventive Benefits for Women, Infants, and Children,” was published as a policy issue brief by the Geiger Gibson Program in Community Health at GW Milken Institute School of Public Health.
No population better illustrates the significance of the Affordable Care Act’s 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.
Researchers closely examined all four categories of preventive benefits included in the ACA’s free coverage guarantee:
- Preventive services recommended for infants, children and adolescents.
- All immunizations recommended by the Advisory Committee on Immunization Practice for children and adults.
- Preventive services recommended specifically for women.
- Preventive services recommended by the United States Preventive Services Task Force (USPSTF).
The lower court decision affects only the USPSTF benefits. But it is likely on appeal that the plaintiffs, a small group of employers and individuals, will challenge the constitutionality of any preventive benefit, across all four categories adopted after March 23, 2010, when the ACA was signed into law.
In this first-of-its-kind analysis, researchers considered the totality of the claims on the context of maternal and child health and found that, of the 192 distinct screening and treatment benefits covered under all four categories, 124 (66 percent) are directly relevant to maternal and infant health. Fifty-five, or 28 percent, focus on children and adolescents.
Among the 124 covered procedures directly relevant to maternal and infant health, only 29 (25 percent) would be maintained in full. Of the procedures, 89 would be eliminated, five would be eliminated for key populations of mothers and infants, and one no longer would offer coverage for 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 COVID-19 and the DTaP-IPV-Hib-HepB vaccines), 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 COVID-19.
Among the 55 procedures directly relevant to children and adolescents, only 24 would be maintained in full, 24 would be lost, five would be eliminated for key populations, and two would be stripped of 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 for “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.
Of the 192 preventive services now covered for all populations, only 48 (25 percent) would remain fully intact.
A total of 121 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. 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.”
Furthermore, 10 recommended procedures would lose essential post-2010 modifications aimed at making them more effective. For example, new approaches to colorectal cancer screening and hypertension screening were recommended post-2010, and these strategies will be lost if the Fifth Circuit upholds Braidwood’s coverage challenge.
“The plaintiffs in this case insist that to satisfy their personal preference for more limited coverage, virtually all Americans, including millions of mothers, infants and children, must lose theirs,” said Sara Rosenbaum, co-author of the report and professor emerita of health policy and management at Milken Institute SPH. “Their demands are not only legally unnecessary but unconscionable.”
