Under the Affordable Care Act, preventive services with no co-pay

October 5, 2013 at 12:00 AM EDT
Find out what the U.S. Preventive Services Task Force (USPSTF) might have to say about your next visit to the doctor. Editor’s Note: Although Medicare regularly provides coverage for preventive services given high grades by the U.S. Preventive Services Task Force, it is not required to do so.

Editor’s Note:

Although Medicare regularly provides coverage for preventive services given high grades by the U.S. Preventive Services Task Force, it is not required to do so.

DR. EMILY SENAY:  Barbara Hillary is shopping for a coat that will keep her warm in sub-zero temperatures.

BARBARA HILLARY: When I’m on expedition it’s all about survival and reaching my goal.

EMILY SENAY: The 82-year-old retired nurse is planning a trip to the arctic – and it won’t be her first.

BARBARA HILLARY: I was the first African-American woman to reach the North Pole, setting a world’s record.  The first African-American woman to reach the North and South Poles, setting another world’s record.

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EMILY SENAY:   Hillary has been an adventurer all her life – and a smoker too.  She had her first cigarette when she was 19 years old and over the years, she smoked close to two packs a day. 

Then one day, Hillary read about a lung cancer screening program using CT scans at a medical college in New York City.  Always willing to try something new, Hillary decided to sign up.  

BARBARA HILLARY:  It occurred to me that this is an avenue that I had not explored.  I was a smoker.  It was available.  So why not take advantage of it?

EMILY SENAY:   And did you have any symptoms?  Were you sick at the time?


EMILY SENAY:   No coughing.


EMILY SENAY:  As it turned out, her first screening showed a cancerous mass in her lungs and she would need surgery.

EMILY SENAY:  Had you not been proactive, what would have happened?

BARBARA HILLARY: I might be dead by now.

EMILY SENAY:  Now under a little publicized part of the Affordable Care Act, other long time smokers like Hillary might soon be entitled to a 300 dollar preventive lung cancer screening with no co-pay.

That’s because of an obscure group known as the United States Preventive Services Task Force. It sounds like an official government body, but it’s actually composed of 16 volunteer and independent physicians and academics.   The group considers what screenings test work and which ones don’t.

Anyone in the medical field can submit a nomination for a seat on the task force, even self-nominations are accepted.  The members are then vetted and selected by an agency within the Department of Health and Human Services.

The group operated with little notice for about 30 years using letter grades to make recommendations to primary care physicians on which preventive services they should offer their patients and helping insurance companies decide what to cover.

Before the Affordable Care Act was passed in 2010, a grade “A” or “B” grade was only a recommendation.

But then under the new law, those grades now require private insurers pick up 100 percent of the costs. 

Doctor Virginia Moyer is the chair of the task force.

VIRGINIA MOYER: The Affordable Care Act includes a provision that says that, ‘Any recommendation that receives an A or B grade from the U.S. Preventive Services Task Force is paid for first dollar,’ so no copay for those recommendations.

Since the passage of the Affordable Care Act, the task force has recommended more than a dozen preventive services: screenings for HIV, cervical cancer and osteoporosis, as well as counseling for obesity and tobacco use, along with vision screenings for children. 

People who need these preventive services can now get them within their insurance networks fully covered.

VIRGINIA MOYER: A preventive service is something that is intended to keep something bad from happening. What we do as a task force is we carefully evaluate the science, the science that tells us whether a preventive service is going to benefit people. 

EMILY SENAY:  The idea is that providing preventive services from the outset will save lives and health care dollars on the backend.

SCOTT GOTTLIEB: On the surface, patients are going to get all of the services that the task force recommends, either A or B, covered in full with no copays.  That sounds good.  I think the problem is that that’s very expensive.

EMILY SENAY:  Doctor Scott Gottlieb is with the conservative think tank American Enterprise Institute, and he says in the medical world – nothing ever comes for free.

EMILY SENAY: For the average person who hears that it is now the law that their insurance company has to pay for preventive services, isn’t that something that most people are going to say is a good thing and they’re going to want as part of their health benefits?

SCOTT GOTTLIEB: You know, I’m concerned about the things that won’t be covered I think you’re going to see more things covered in full that the task force recommends and more things not covered at all that that task force doesn’t recommend.

EMILY SENAY: If the task force says that insurance companies have to pay for something, like screening for lung cancer, and it costs a lot of money, aren’t they just gonna take money from other things?

VIRGINIA MOYER: The Affordable Care Act, what it says is that insurance companies have to pay for A and B recommendations.  It says nothing at all about what doesn’t get paid for.  That then remains the decision of insurance companies and of course for many people – it’s the decision of Medicare.

EMILY SENAY: And the decision of the insurance companies like AETNA has been to stick with the task force says. Doctor Lonny Reisman is its chief medical officer. 

DR. LONNY REISMAN: We’ve mostly covered all of the mandates already.  So they’re baked into our premiums, and we’re not expecting a significant increase in costs. 

EMILY SENAY: But he says the real financial challenge will be to manage costs and at the same time satisfy customers as more services are mandated in coming years.

DR. LONNY REISMAN: We are compelled to cover it. We are committed to covering it.  And any increases in costs will be covered in our premiums, but we will explain the basis for in fact increasing premiums as a result of increasing medical costs.

EMILY SENAY: That could mean no out of pocket expenses for preventive services at the doctor’s office but higher insurance bills for consumers.

And there’s still another aspect of this story, whether there’s the same oversight of the volunteer task force as there is of other government agencies.

SCOTT GOTTLIEB:  I have a problem with a government entity functioning as a regulatory agency, not being subject to any of the rules that govern good regulation writing and good rule making, basically having binding authority over what the entire country’s going to have access to.  And that’s what they have right now.  They’re going to determine coverage, not just for Obamacare, not just for Medicare, but for everyone.

EMILY SENAY: Controversy about the task force has been especially heated when its decisions have been reversed or gone against the grain of the wider medical community. 

For instance in 2009, the task force recommended against routine mammograms for women before the age of 50 – changing an earlier recommendation that said women should be screened at 40.

But despite being more visible these days, the chair of the task force says, they’ll continue doing their job, reviewing scientific evidence so they can keep Americans healthy.

DR VIRGINIA MOYER:  We want to be independent and we want our recommendations to be based on science, not politics. If you look at our website, it ends in .org.  It doesn’t end in .gov, so we’re an independent panel.  We are epidemiologists and primary care clinicians. We are not policymakers.

EMILY SENAY: Even as the debate about the role of the task force continues, explorer Barbara Hillary says she’s just grateful she got her early screening.

BARBARA HILLARY: To me it’s just so obvious that I was able to live.

EMILY SENAY:  As a result…

BARBARA HILLARY:  As a result of the screening program.

Living is not inhaling and exhaling.  Living is– you know you feel it.  And if you don’t feel it, baby you ain’t livin’.