UPDATE: Since publishing this post about the US Preventive Services Task Force around 2 p.m., I have been told by the White House that my interpretation of the Senate legislative language is off. This was, incidentally, the interpretation of several non-partisan policy experts I spoke to as well, but that doesn’t matter. What matters is setting the record straight. The White House says that the section of the Senate health reform bill I quoted…
‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
‘‘(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for— ‘‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;
…only means that US Preventive Task Force recommendations would determine which preventive services private insurers would be federally required to cover at no cost to patients. Linda Douglass, the communications director for the White House Office of Health Reform, says, “The Secretary [of Health and Human Services] would have the discretion to add other preventive benefits to the essential benefits package.” This means, under the Senate bill, the task force would decide which preventive services private insurance beneficiaries would get at no out-of-pocket costs. As for other preventive services – including those requiring co-pays or co-insurance – that would be up to HHS.
It’s important to be clear on these provisions in the bill, because the coverage requirements for private insurers would be some of the most consequential effects of health reform. But it’s also important to point out that while the Secretary of Health and Human Services may have a different opinion than the HHS-affiliated US Preventive Services Task Force on which preventive services are essential enough that patients should be able to get them without shelling out any cash, the task force’s guidelines would not be ignored by federal health officials under reform. By federally requiring certain preventive services be fully paid for by insurers, the government would essentially be saying: These particular services are too important. We can’t risk Americans forgoing them because of cost. The government would, by default, not be saying the same thing about other preventive services – like annual breast cancer screening for women 40-49 – that the US Preventive Task Force does not recommend by routine. It’s also important to point out that, whether its the US Preventive Services Task Force or the Secretary of Health and Human Services, the federal government would – under health care reform – have a big say in what medical care private insurers would have to cover, a change from the current state of affairs that’s great or terrible, depending on your opinion about the role of government in health care.
My full original post follows below:
Ever since the US Preventive Services Task Force said annual breast cancer screening should not be routine for women in their 40s, Democrats have been eager to assert that the panel does not set federal policy. In response to the immediate political and public uproar over the new guidelines, Health and Human Services Secretary Kathleen Sebelius released a statement saying, in part:
“The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government.”
Then Senate Majority Leader Harry Reid followed a few days later with a statement including this:
“…let’s be clear: the task force’s recommendation will have absolutely no impact on the bills we in the Senate write, debate or vote on. Secretary Sebelius has also assured me there that nothing in Medicare or Medicaid will change as a result of the recommendation, and that’s the way it should be.”
These statements are technically true, but if you read them and were left with the impression that the task force and Democratic health reform legislation are unrelated, you should take a closer look at the Senate bill, currently under debate in the chamber.
From Page 17 of the Senate health reform bill:
‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
‘‘(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for— ‘‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;
This means if the Senate bill became law, the task force recommendations would accomplish two things: they would set the floor for what preventive services private insurers would be required to cover and they would require private insurers to fully cover those services at no cost to patients. If the Senate bill were law today, the list of preventive services private insurers would be federally required to fully cover would not include routine annual mammograms for women in their 40s. (UPDATE: I rewrote the previous sentence, which in my original version erroneously said that insurers would stop covering routine mammograms for women in their 40s under the Senate bill. As the White House points out, most states – like Rhode Island, which I mention below – currently require insurers to cover screening for these women anyway. Plus, private insurers are free to continue the coverage for any procedure even if not required to by law.) Here’s how the task force guidelines work:
The task force grades various preventive medical procedures on an A to D scale. Procedures with an A rating are recommended with “high certainty that the net benefit is substantial”; B ratings are also recommended with “high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.” C ratings are for procedures that the task force says should not be routine and D ratings are for procedures the task force says should not be performed. (The task force also has an I rating for procedures for which there is not enough evidence to make a recommendation for or against.) Put more simply, the task force says medical procedures in categories A and B are recommended. The task force’s new guidelines moved annual routine mammograms for women in their 40s moved from category B (the 2002 recommendation) to category C, saying women should consult with their doctors. (The task force recommendations only apply to women who are not “at risk” of getting breast cancer because of genetic mutations or family history.)
Of course, even under the Senate bill, private insurance companies could still choose to cover routine annual mammograms for 40-something women and many experts predict they would. There is lots of debate over whether the task force’s new guidelines are in the best interest of patients. The American Cancer Society and National Cancer Institute, for example, still recommend routine screening begin at age 40. Given this – and the political lightening rod that mammograms have always been – private insurers seem unlikely to change their coverage anytime soon.
As for Medicare, under the Senate bill, recommendations from the US Preventive Services Task Force would not determine what preventive services would be covered. But recommendations from the task force would determine what preventive services Medicare must cover at 100%. Currently, most preventive services covered by Medicare require that beneficiaries pay a percentage of the total cost. Under the Senate bill, this cost sharing – for preventive services in the task force’s categories A and B – would be eliminated.
In response to questions about the role of the task force, Linda Douglass, the communications director for the White House Office of Health Reform sent me an e-mail agreeing that the panel would play a central role in preventive medicine under health reform:
In the current versions of the health insurance reform legislation, these recommendations could form the basis for coverage of preventive services that should be offered for free—services that are unavailable to millions of Americans today. These recommendations would be the minimum–the floor– upon which plans should be built. The panel’s recommendations will not be used to deny coverage. Nothing about these recommendations will prevent your insurance company from covering mammograms as they do today; and the insurance industry has made clear it will continue to be strongly influenced by what doctors recommend.
Douglass is right that no insurer will be prevented from covering a services – it will up to insurers to decide what preventive services they want to cover beyond what’s required. Douglass’s contention that “the panel’s recommendations will not be used to deny coverage” (emphasis mine) is also correct, although insurers could absolutely use the panel’s recommendations to decide in advance which services to cover, which is different than refusing to cover something after the fact.
The bottom line is that there is currently no federal requirement that private insurers cover preventive medicine and covering preventive medicine, in most cases, saves money in the long run and keeps people healthier. (State insurance regulators, however, can require certain services be covered. Shortly after the new task force guidelines were released, for example, the Rhode Island insurance commissioner issued a press release assuring residents that state law will continue to require insurers cover annual routine mammograms for women 40-49.) But if health reform legislation is going to require insurers to start fully covering preventive services on a federal level, some entity has to decide what procedures fit into this category. Under the Senate bill, that entity would be the US Preventive Services Task Force, which is comprised of 16 health professionals, including 14 physicians.