ACA repeal could reverse gains in screening

The Affordable Care Act (ACA) out-of-pocket provision for preventative care increased screening uptake, especially among lower-income patients, but the ACA’s impending repeal could undo those gains, according to industry experts.

From a population health standpoint, the effectiveness of widespread preventative care is unquestionable: It leads to longer, healthier lives for patients and significant cost savings all around, according to the National Commission on Prevention Priorities.

Patients without health insurance have limited options for affordable preventative care, but the out-of-pocket costs associated with screening can put mammography or colonoscopy out of reach even for insured Americans, according to a study conducted by HHS.

A key tenant of the ACA was the requirement that insurers pay out-of-pocket costs for a list of US Preventative Service Task Force (USPSTF)-recommended screening measures. Researchers from the University Hospitals of Cleveland set out to quantify the change in screening rates when that financial barrier was removed, finding that mammography rates increased, especially among the poorest cross-sections of the population. 

Their retrospective study was published in Cancer, the journal of the American Cancer Society. 

“Anyone will tell you that preventative care is the most cost-effective way to practice medicine,” said Gregory Cooper, MD, an author on the study. “For mammography, it’s pretty straightforward; you don’t have to go through an intermediary, your primary care provider can order the test—there aren’t any other real obstacles.”

However, Cooper and his colleagues found colonoscopies to be a different story, recording uptake rates that didn’t change after the passage of the ACA.

“I think it’s because the colonoscopy is a little bit more of a process,” he said.

In addition, Cooper would like to see pap smears added to the USPSTF list of recommended screening, saying even though they are slightly invasive, they are a “straightforward screening” that patients would be likely to adopt.

In any case, the imminent repeal of the ACA and the uncertainty of its replacement throw these population health triumphs into turmoil. While President-elect Trump has voiced support for keeping certain parts of the ACA, namely the clauses regarding pre-existing conditions and children staying on parents’ plans until age 26, the remainder of his healthcare plan is mostly unknown.

Radiology advocacy groups such as the American College of Radiology (ACR) want the out-of-pocket provision to be viewed in the same light as covering pre-existing conditions, according to Chris Sherin, Director of ACR Congressional Affairs.

“It’s something we think makes a lot of sense,” said Sherin. “Detecting disease early is fiscally responsible because you can treat something at an earlier stage when it’s cheaper to treat, but it’s also a great thing for the patient, because you’re catching it earlier when it’s more likely to be cured.”

While the word on out-of-pocket costs is mum, Sherin expects any ACA replacement to contain some combination of state-run high-risk pools, greater access to health savings accounts, and allowing insurance to be sold over state lines—all pillars of GOP proposals such as Paul Ryan’s A Better Way or Tom Price’s Empowering Patients First Act.

“How much of that is retained with what they ultimately do, I don’t know, but those are the themes we’re hearing more and more,” said Sherin.