Outcome of Braidwood v. Becerra appeal will affect out-of-pocket costs for millions of consumers

As many as 10 million Americans could face higher out-of-pocket costs if a district court decision regarding preventive health coverage provisions of the Affordable Care Act is upheld on appeal, a KFF report found.

The ACA requires most private plans to cover in-network preventive services at no cost to enrollees. In March, however, the U.S. District Court in the Northern District of Texas ruled in the case of Braidwood Management v. Becerra that this mandate is partially unconstitutional. The decision excluded all preventive care recommendations issued by the United States Preventive Services Task Force on or before March 23, 2010, when the ACA was signed into law.

“As a result, the ruling could affect more services and people over time as new drugs and treatments are developed, recommended and adopted,” according to the report. “For example, this analysis — which relies on 2019 claims data to reflect utilization in a typical pre-pandemic year — does not consider the ruling’s impact on more recent preventive service recommendations, like PrEP for HIV.”

Among treatments approved in and before 2010, the ruling would not affect the costs of other common preventive services, such as vaccines recommended by the Advisory Committee on Immunization Practices, women’s preventive health services or mammography and cervical cancer screenings.

Earlier this month, the Fifth Circuit Court of Appeals issued an administrative stay as the Biden administration appeals the decision. Separately and before the stay, major private health insurers announced that they do not plan to make changes to coverage of preventive services until a final ruling has been made. Some insurers and employers may introduce cost sharing over time if the district court ruling holds.

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“While the stay is in effect, the federal government can continue to enforce the ACA preventive services mandate for everyone except the plaintiffs in the case,” the report said. “If the Fifth Circuit Court stay is lifted and the district court’s decision is affirmed by a higher court, insurers would be allowed to introduce cost-sharing for any of the affected preventive services and drugs or exclude coverage altogether, though the latter appears to be the less-likely scenario.”