By Surabhi Dangi-Garimella, Ph.D.

For more than a decade now, health plans have been modeling their benefit structure to encourage enrollees to use certain “high-value” services—whose clinical benefits supersede the cost—and discourage the use of “low value” services, whose benefits do not match the associated cost. This is the essence of value-based insurance design or VBID. 

The Affordable Care Act (ACA) has adopted VBID strategies to ensure cost-efficient health care delivery that is mindful of patient cost sharing.  A significant provision within the ACA requires non-grandfathered health plans to provide first-dollar coverage—meaning zero cost-sharing for the patient—for wellness/preventive services. Section 2713 of the ACA ensures much-needed access to wellness care. However, not all preventive care services are necessary, and the ACA allowed Medicare health plans to stop coverage for certain services that do not improve health.  

This website on health benefits provides a complete list of all preventive health services that should be covered by most health plans without any cost sharing for all adults and specific services for women and children. 

What determines the value of preventive care services? The coverage determination is made based on recommendations by expert advisors who are on various panels: U.S. Preventive Services Task Force (USPSTF) for preventive services, Advisory Committee on Immunization Practices (ACIP) for the right vaccines, and Health Resources and Services Administration (HRSA) for preventive care for women and children.

Eliminating Cost-sharing Increased Preventive Care Utilization

According to a review of several studies conducted by authors from the University of Michigan Center for Value-Based Insurance Design, utilization of preventive care services that were completely covered by health plans without any patient cost sharing, increased following the ACA. The greatest benefit was seen among those who had financial barriers to receiving preventive care—low-income individuals, Medicare-insured without supplemental insurance, and those who faced a high cost for a preventive service before the cost was eliminated.       

According to Mark Fendrick, MD, director of the center, “Our findings indicate that any potential removal of its provision to eliminate patient costs for preventive care could have negative implications, especially for those who are financially vulnerable.” 

The following preventive screenings saw increased use after health insurers completely covered the cost, without any patient cost-sharing: 

  • Breast cancer screening: 50% of the studies in the review concluded that reduction in cost-sharing increased use of this screening test, especially among African Americans and Medicare enrollees without supplemental insurance
  • Colon cancer screening: Increase in use observed by three studies following elimination of cost-sharing for screening colonoscopy. However, the authors identified barriers that were bigger than the cost of the colonoscopy:
    • Lost wages because of the need to take time off from work
    • Discomfort associated with the test
    • Fear of complications
  • Contraception/sterilization: Increased use of both, long-acting reversible contraception and short-term methods such as pills and patches. Biggest increase was seen in use of long-acting contraception among women who saw a big drop in cost-sharing.

Another study, which analyzed preventive care utilization after elimination of cost-sharing from a racial disparities’ perspective, found:

  • 3.6% increase in colonoscopy use and 3.1% increase in mammogram use by a privately insured Hispanic person
  • 2.3% increase in colonoscopy use and 2.4% increase in mammogram use by a privately insured African American person

The control group in this study was non-Hispanic whites on Medicaid.

Lawsuits Could Revert Preventive Services Coverage 

Two lawsuits have been filed that can impede patient access to these preventive care services. In Leal v. Becerra, the plaintiffs claimed that HRSA does not have the power to legally bind private parties—in this case, group health plans and health insurance issuers—to adopt preventive care services. The case is now in front of the Fifth Circuit Court following rejection by a federal district court. Plaintiffs who filed Kelley v. Bacerra also had similar claims that non-governmental bodies—the USPSTF, ACIP, and HRSA—cannot have the authority to make laws as they are not officers of the government. A federal district court in Texas granted a motion to this filing and a verdict is expected in 2022.

Despite targeting only a portion of the ACA, reverting the preventive care services can have widespread impact on everything from vaccinations (flu shot, COVID-19 vaccine) to substance abuse counseling.


Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brings her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.