A recent letter from the Congressional Research Service (CRS) reveals how Obamacare will erode patients’ access to certain preventive services.
The new health care law requires insurers to cover all preventive measures rated “A” or “B” by the United States Preventive Services Task Force (USPSTF) with zero cost-sharing. Otherwise, “a plan or issuer has the discretion to either cover or not cover additional preventive services not recommended by the USPSTF,” according to the CRS letter.
While many of the more specific task force recommendations are already included in most health plans, some are less clear cut. Before the passage of the new law, Heritage expert Ed Haislmaier wrote that turning these general recommendations into requirements means the “HHS would need to draft and promulgate regulations detailing the type, scope, frequency, and duration of the specific services that must be covered—along with rules on which providers must be paid for providing which services, and the criteria under which specific patients qualify for specific services.”
The Human Health and Services Department so far has punted on this score. In its recent interim final regulations, the agency said,
“[If] a recommendation or guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations”
“The use of reasonable medical management techniques allows plans and issuers to adapt these recommendations and guidelines to coverage of specific items and services where cost sharing must be waived. Thus, under these interim final regulations, a plan or issuer may rely on established techniques and the relevant evidence base to determine the frequency, method, treatment, or setting for which a recommended preventive service will be available without cost-sharing requirements to the extent not specified in a recommendation or guideline.”
In addition to creating more uncertainty, requiring coverage of all “A” and “B”-rated interventions will increase costs, encouraging plans to drop any preventive measure that isn’t recommended by the task force.
The task force’s decision last November to downgrade mammograms for women aged 40 to 49 to a “C”-rating (i.e., not recommended) illustrates the type of service that may no longer be covered. Rather than providing a black-and-white threshold for mammogram screening, Drs. Kerianne Quanstrum and Rodney Hayward, write that the task force “simply recommended that routine screening mammography begin at the age of 50 years, whereas women between the ages of 40 and 49 years should make individual decisions with their doctors as to whether their preferences and risk factors indicate screening at an earlier age.”
But Congress has written the law in such a way that it is likely that some patients who might need screening would not be covered under the new rules. Why: Because Congress transfers real decision making to regulators; and regulators can affect the care of widely different patients in arbitrary ways.
Consider last year’s controversial mammogram decision. It will not initially be included in the recommendations used to determine the required preventive measures or screenings. But the CRS letter notes that if the task force makes the same recommendation in the future, it will be. And controversial recommendations for other preventive services are sure to follow.
The only path for recourse on controversial recommendations will be through Congress. Ultimately, this requirement could serve as a roadblock for some patients to get the proper preventive care that they need. In sound health care reform, doctors and patients, not bureaucrats, would make the key decisions.
