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Court Case Challenges Private Insurance Coverage for Screening Costs

A recent court case called Braidwood Management Inc. v. Becerra has received a lot of attention in the public health and cancer patient advocate communities.

Current law requires private insurance companies to provide no-cost coverage for lung cancer screening, which LUNGevity supports. This court case could negate that requirement. This case will not directly impact Medicaid or Medicare, which also covers the cost of lung cancer screening.

In this blog post, we provide some background on the case, its implications for lung cancer, and actions that LUNGevity is taking in response to the latest developments.

Background

The Affordable Care Act (ACA), signed into law in 2010, includes a provision that requires coverage for preventive services with no patient cost-sharing if the service receives a rating of “A” or “B” from the United States Preventive Services Task Force (USPSTF). The USPSTF is an independent panel of experts that reviews evidence and makes recommendations for services such as cancer screenings, behavioral counseling, and medications that can help prevent certain diseases.

The court case Braidwood Management Inc. v. Becerra was brought by a group of plaintiffs including businesses and individuals who argued that it was unconstitutional to require private health insurance to cover certain preventive services.

Part of their argument is focused on the way that members of the USPSTF and other panels are appointed (by an agency head instead of the president), and they have claimed that this makes mandating coverage based on the panel’s recommendations unconstitutional. The federal government has countered that there are several examples of similarly appointed panels making binding recommendations.

Implications for Lung Cancer

The USPSTF made its original recommendation of a “B” rating for low-dose computed tomography (LDCT) for lung cancer screening in 2013 and updated the recommendation to broaden the impacted population in 2021. LDCT is currently the only guideline-recommended screening for lung cancer.

In his March 2023 ruling, U.S. District Court Judge Reed O’Connor struck down part of the coverage requirement in the ACA, meaning that the government cannot mandate coverage for services that received an A or B rating by the USPSTF on or after March 23, 2010 (the date the ACA went into effect).

If the ruling stands, private insurers would not be required to provide coverage for screening tests such as LDCT and many other services recommended by the USPSTF. While some insurers have publicly stated that they do not intend to change coverage for such services at this time, the decision has raised serious concerns about long-term coverage for potentially life-saving screenings.

LUNGevity’s Position

LUNGevity is very concerned about the impact that this ruling could have on access to screenings including LDCT as the cost may or may not be covered by insurers. We issued a statement following the March ruling, specifically calling attention to the implications for lung cancer. The Biden Administration has since appealed the decision to the 5th Circuit Court of Appeals.

LUNGevity joined partners including the American Lung Association and American Heart Association in supporting an amicus curiae brief requesting that the 5th Circuit Court of Appeals grant a stay of the district court judgement while the case is on appeal so that that access to services such as LDCT is not affected during the process. On May 15, the 5th District Court of Appeals issued an administrative stay in the case, a decision that was supported by LUNGevity and other leading patient and public health organizations in a statement released that same day.  

What’s Next?

As of this writing, oral arguments before the 5th Circuit Court of Appeals have just begun. The case is widely expected to ultimately reach the Supreme Court, and while the timeline is uncertain, the process could take several months if not years.

In the meantime, LUNGevity will continue to work with our partners to ensure that access to lung cancer screening and other important services is protected. This will include continued engagement on the case as well as on potential policy solutions on the federal and state levels. We will continue to keep our network informed about news and potential advocacy opportunities related to this topic. For more detailed background on this case, please see this article from KFF.

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