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Stronger Push Needed for Preventive Care

ACA’s Expansion of Preventive Screening Doesn’t Do Enough (Volume10, Issue 19)

The Affordable Care Act expanded coverage and patient protections but failed to make health care affordable, with health spending now nearly 20% of U.S. GDP and growing. One aspect of the ACA that aimed to improve access and cut costs was the little-known mandate requiring all private insurers to offer certain preventive care screenings for no out-of-pocket costs. A 2010 study in Health Affairs purports that widespread preventive screening not only would improve health but also could save billions of dollars. An example: If we detect high blood pressure and cholesterol early, we treat them with medication and lifestyle changes; if we fail to diagnose them before the patient suffers a heart attack, the patient may experience permanent debilitation and require more resources in the ER, cath lab, and cardiac care unit.

NIAID (Flickr/Public Domain)

A recent study investigated whether the ACA’s preventive care requirements led to an increase in preventive screening and early diagnosis of disease. The authors focused on respondents who were privately insured before and after ACA implementation because this provision affects only the privately insured. They assessed rates of compliance with seven screening tests (routine checkup, flu vaccination, blood pressure, cholesterol, pap smears, mammography, and colorectal cancer screening) and rates of diagnosis for the seven conditions for which those screenings are performed. Using difference-in-difference analysis, the authors compared screening and diagnosis rates of this privately insured population with rates in the uninsured population.

The results were underwhelming. Only two screening services – routine checkup and flu vaccination – showed increased rates under the ACA, and these modest increases were seen mostly in high-income families. Further, no significant increase in rate of diagnosis nor decrease in out-of-pocket costs were found.

Because this study surveyed only the privately insured, it cannot account for increases in preventive care for millions who gained coverage via Medicaid. Further, because the study compared percentages of privately insured persons who utilized these services, it does not account for marketplace subsidies’ effect on the number of privately insured. Still, the ACA’s preventive care provision has been inadequate in correcting the fact that half of Americans don’t receive recommended preventive care.

Since these services are free at the point of service, the problem must lie with awareness. And because we can improve health with little increase in spending, we should support public education campaigns to boost utilization of preventive screenings.

This Policy Prescriptions® review is written by Benjamin Sketchler. He is a medical student at Baylor College of Medicine.


BACKGROUND: The utilization of preventive care services has been less than optimal. As part of an effort to address this, the Affordable Care Act (ACA) mandated that private health insurance plans cover evidence-based preventive services.

OBJECTIVES: To evaluate whether the provisions of ACA have increased being up-to-date on recommended preventive care services among privately insured individuals aged 18-64.

RESEARCH DESIGN: Multivariate linear regression models were used to examine trends in prevalence of being up-to-date on selected preventive services, diagnosis of health conditions, and health expenditures between pre-ACA (2007-2010) and post-ACA (2011-2014). Adjusted difference-in-difference analyses were used to estimate changes in those outcomes in the privately insured that differed from changes in the uninsured (control group).

RESULTS: After the passage of ACA, up-to-date rates of routine checkup (2.7%; 95% confidence interval, 0.8%-4.7%; P=0.007) and flu vaccination (5.9%; 95% confidence interval, 4.2%-7.6%; P<0.001) increased among those with private insurance, as compared with the control group. Changes in blood pressure check, cholesterol check and cancer screening (pap smear test, mammography, and colorectal cancer screening) were not associated with the ACA. Prevalence in diagnosis of health conditions remained constant. Slower uptrends in adjusted total health care expenditures and downtrends in adjusted out-of-pocket costs were observed during the study period.

CONCLUSIONS: The provisions of the ACA have resulted in trivial increases in being up-to-date on selected preventive care services. Additional efforts may be required to take full advantage of the elimination of cost-sharing under the ACA.

PMID: 28671929

Hong, YR, et al. Med Care. 2017 Aug;55(8):771-780.