Dr Mark Fendrick Discusses How the Braidwood Ruling Could Affect Cost-Sharing

A. Mark Fendrick, MD, director of the V-BID Center at the University of Michigan and co-editor in chief of The American Journal of Managed Care, spoke with AJMC about how the Braidwood v Becerra ruling has implications for cost sharing in different treatment types.

Transcript

How could the Braidwood v Becerra ruling potentially affect cost sharing?

One of the aspects of the way this small section of the ACA [Affordable Care Act] that I helped work on is written is that it's a gift that keeps on giving. So it's not like this list exists from 2010; it is these 3 organizations that Professor [Nicholas] Bagley mentioned. Most notably, the US Preventive Services Task Force continues to work on well over a dozen different preventive services at one time, 6 of which actually have draft A or B ratings now, including anxiety screening and intimate violence and other types of services that are likely to get an A or B final rating.

But if this legal decision were to hold, these services would not be mandated to have zero cost sharing. So while I am confident, and our own research shows that many payers will probably stick with the services that currently have an A or B rating and not change them—although 20% say they may not—I am particularly worried about the gift that keeps on giving, in the fact that I'm less confident that payers will continue to embrace zero cost sharing for new services that have A or B ratings.

The last point that I think is worth mentioning is that many people do not know that it was actually the preventive care section of the ACA that was amended to allow zero cost sharing for COVID testing, vaccines, and treatments. And since we didn't even know what COVID was until long after 2010, that if this lawsuit would be upheld, the current status of zero cost sharing for COVID diagnostics, vaccines, or treatments is likely to go away.

So I do have concerns, particularly since our own review of the literature of these programs that have eliminated cost sharing has shown disproportionate positive benefit for underserved populations. I do worry about the equity implications of, what I like to say, going back into the future and seeing some of these older recommendations being adopted as opposed to the newer ones, or even worse having the newer ones being completely eliminated.

So I'm so thrilled to have learned from Professor Bagley and colleagues, and I am hopeful to work with a very strong multistakeholder coalition to bring the benefits and the merits of restoration of the preventive care provisions of the ACA and have the legal language that Dr. Bagley has helped us all with be approved and we could go back to where we were, such that 150 million Americans at least, not including the COVID beneficiaries who have benefited from this very tiny section of the Affordable Care Act, will continue to be able to have unfettered access to evidence-based preventive services moving forward.