平價醫療法案 (ACA) 下的免費預防性照護再次受到威脅——一項將 PrEP 排除在保險範圍之外的裁決可能會擴展到全國和其他醫療服務
資料來源：保羅. 謝弗，克里斯蒂弗·斯托亞諾夫斯基 / 英國夏令時 2022 年 9 月 13 日下午 1:33 /
The Conversation
如果按照指示服用，PrEP 在預防 HIV 感染方面幾乎 100% 有效。
圖片來源：時代/蓋洛圖片透過蓋蒂圖片社社論
在 2021 年 6 月歷經第三次重大法律挑戰之後，當最高法院保留了《平價醫療法案》時，許多美國人鬆了一口氣。這一決定留下了廣泛支持的政策，例如確保覆蓋範圍不考慮先前存在的條件，根據父母的計畫增加對受撫養人的覆蓋範圍到 26 歲，並取消年度和終生福利限制。
但衝擊不斷湧現。《平價醫療法案》提供的最受歡迎的福利之一是免費預防保健，再次受到 Braidwood Management 訴 Becerra 的法律威脅——最初是 Kelley 訴 Becerra。 Braidwood 的原告是個人和企業主的混合體，他們反對購買涵蓋暴露前預防或 PrEP 的保險，這種藥物在預防 HIV 感染方面幾乎 100% 有效。其中一名原告聲稱，PrEP「促進和鼓勵同性戀行為、靜脈注射毒品以及男女之間的婚外性行為」，並且他的宗教信仰使他無法提供涵蓋 PrEP 的保險。
2022 年 9 月 7 日，德克薩斯州法官里德·奧康納 (Reed O’Connor) 發布裁決，認為保險計畫涵蓋 PrEP 的要求侵犯了原告的宗教自由。他還裁定，《平價醫療法案》將有關預防保健費用分攤的決定委託給美國預防服務工作組做出了過激行為。這項裁決最終會影響到那些人，以及它是否最終會取消完全涵蓋其他預防性照護的要求，如免費流感疫苗和癌症篩查，則還有待確認。
我們是波士頓大學和杜蘭大學的公共衛生研究人員，研究健康保險、預防和性健康。由於這項政策現在處於危險之中，美國的預防和健康公平之推動將向後倒退一大步。
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《平價醫療法案》和預防保健
《平價醫療法案》第 2713 條要求保險公司提供由下列三個聯邦團體之一認可的預防性服務的全面覆蓋：美國預防性服務工作組（the U.S. Preventive Services Task Force ，包括A 或 B 級）、預防接種實踐諮詢委員會（the Advisory Committee on Immunization Practices）和衛生資源和服務管理局（the Health Resources and Services Administration）。如果他們推薦該程序或介入措施作為重要的預防性照護，那麼您不必自掏腰包支付任何費用。例如，《CARES 法案》使用此規定來確保許多美國人可以免費接種 COVID-19 疫苗。
《平價醫療法案》自實施以來顯著降低了兒童健康門診的費用。圖片來源：約翰·費德勒/蓋蒂圖片社的圖像銀行
PrEP 在 2019 年 6 月獲得 A 級評級，為數百萬人免費提供 PrEP 和相關服務（如診所就診和實驗室測試）鋪平了道路。
儘管《平價醫療法案》的第 2713 條並不完美，有時會讓患者因意外的賬單而感到沮喪，但它在降低兒童健康門診和乳房 X 光檢查等服務的成本方面發揮了巨大的作用，僅舉前開幾例。
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法律論據
最新案件的依據是與 PrEP 無關的法律技術問題，而是美國預防服務工作組是否可以行使《平價醫療法案》授予他們的權力，以及原告的宗教自由是否受到侵犯。
奧康納同意，允許美國預防服務工作組獲得這一權力違反了憲法的任命條款，該條款規定使用政府權力的人必須是「美國官員」。在這種情況下，奧康納裁定美國預防服務工作組成員確實有資格擔任官員，但他們的任命是違憲的，因為他們不是由總統任命並得到參議院的確認。
這為廢除第 2713 條鋪平了道路，並允許保險公司決定哪些預防性照護（如果有的話）在患者的計畫中仍然免費。他還辯稱，因為《平價醫療法案》「迫使 Braidwood [覆蓋] 它持有真誠宗教反對意見的服務……提供覆蓋本身就是對 [原告] 認為服務鼓勵的行為的默許」。
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無法獲得預防保健
PrEP 是美國「終結 HIV 流行」倡議的預防支柱的主要組成部分，並成功地降低了高度使用地區的 HIV 新診斷率。如果這項裁決在全國範圍內擴大，超過 170,000 名當前的 PrEP 用戶和超過 100 萬可以從該藥物中受益的人可能會受到影響。
PrEP 是幫助美國實現到 2030 年大幅減少新的 HIV 感染目標的關鍵工具。圖片：Pablo Martinez Monsivais / 美聯社照片
消除 PrEP 的成本障礙使其更容易透過商業保險獲得，商業保險是超過三分之二 65 歲以下人口的主要健康保險來源。再次提高成本障礙將不成比例地傷害年輕患者、有色人種和低收入人群。男男性行為者中的黑人男性可能會因為他們所面臨的結構性障礙而受到特別的影響，儘管平均而言，他們的性行為並不比其他男男性行為者的男性更「危險」。
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下一步是什麼？
目前，裁決的宗教自由部分特定於 PrEP 和 Braidwood Management 購買涵蓋 PrEP 的計畫。目前尚不清楚該命令是僅適用於這些原告還是全國範圍內。
下一份文件將於 2022 年 9 月 16 日提交，雙方將開始提供更多關於他們認為應該如何應用該裁決的信息。到目前為止，還沒有具體決定的時間表。
目前，繼續提供由《平價醫療法案》免費提供的 PrEP、避孕、癌症篩查和所有其他形式的預防保健。不管奧康納的最終決定如何，此案似乎很可能會上訴到最高法院，屆時將決定另一場關於《平價醫療法案》很大一部分命運面臨的攤牌。
本文的部分內容最初出現在 2021 年 9 月 7 日和 2021 年 12 月 1 日發表的先前文章中，最近發佈時間：英國夏令時間 2022 年 9 月 13 日下午 1:33
作者：
1.保羅. 謝弗
波士頓大學衛生法、政策和管理助理教授
2.克里斯蒂弗·斯托亞諾夫斯基
杜蘭大學社會、行為和人口科學研究助理教授
披露聲明：
過去三年，Paul Shafer 獲得了來自英聯邦基金、Arnold Ventures、Robert Wood Johnson Foundation、Kate B. Reynolds Charitable Trust、星巴克咖啡公司和 Renova Health 的資助。
Kristefer Stojanovski 過去曾獲得羅伯特伍德約翰遜基金會、美國國家少數族裔健康與健康差異研究所、國家心理健康研究所和富布賴特項目的資助
夥伴關係：
波士頓大學作為 The Conversation US 的創始合夥人提供資金。
我們相信信息的自由流動
在知識共享授權條款許可下，我們以免費、在線或印刷方式重新發布已發布的文章。
Free preventive care under the ACA is under threat again – a ruling exempting PrEP from insurance coverage may extend nationwide and to other health services
Paul Shafer & Kristefer Stojanovski / September 13, 2022 1.33pm BST / The Conversation
PrEP is almost 100% effective in preventing HIV infection when taken as directed. The Times/Gallo Images via Getty Images Editorial
Many Americans breathed a sigh of relief when the Supreme Court left the Affordable Care Act in place following the law’s third major legal challenge in June 2021. This decision left widely supported policies in place, like ensuring coverage regardless of preexisting conditions, coverage for dependents up to age 26 on their parents’ plan, and removal of annual and lifetime benefit limits.
But the hits keep coming. One of the most popular benefits offered by the ACA, free preventive care, is under legal threat again by Braidwood Management v. Becerra – originally Kelley v. Becerra. The Braidwood plaintiffs are a mix of individuals and business owners who object to purchasing insurance that covers preexposure prophylaxis – or PrEP – a medicine that is almost 100% effective in preventing HIV infection. One of the plaintiffs claimed that PrEP “facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman” and that his religious beliefs prevent him from providing insurance that covers PrEP.
On Sep. 7, 2022, Texas Judge Reed O’Connor issued a ruling that the requirement for insurance plans to cover PrEP violated the religious freedom of the plaintiffs. He also ruled that the ACA overstepped in delegating decisions about cost-sharing for preventive care to the U.S. Preventive Services Task Force. Who this ruling will ultimately affect and whether it will eventually get rid of the requirement to fully cover other preventive care, like free flu shots and cancer screening, has yet to be confirmed.
We are public health researchers at Boston University and Tulane University who study health insurance, prevention and sexual health. With this policy now in jeopardy, prevention and the push for health equity in the U.S. stand to take a big step backward.
The ACA and preventive care
Section 2713 of the ACA requires insurers to offer full coverage of preventive services that are endorsed by one of three federal groups: the U.S. Preventive Services Task Force (with an A or B rating), the Advisory Committee on Immunization Practices and the Health Resources and Services Administration. If they recommend the procedure or intervention as important preventive care, then you shouldn’t have to pay anything out of pocket. For example, the CARES Act used this provision to ensure COVID-19 vaccines would be free for many Americans.
The Affordable Care Act significantly reduced the costs of well-child visits since it was instated. John Fedele/The Image Bank via Getty Images
PrEP received an A rating in June 2019, paving the way for both PrEP and related services like clinic visits and lab tests to be covered at no cost for millions of people.
Though Section 2713 of the ACA doesn’t work perfectly, sometimes leaving patients frustrated by unexpected bills, it has made a huge difference in reducing costs for services like well-child visits and mammograms, just to name a few.
The legal arguments
The latest case rested on legal technicalities that have nothing to do with PrEP, but rather whether the U.S. Preventive Services Task Force can wield the authority granted to them by the ACA, and whether the religious freedom of the plaintiffs was violated.
O’Connor agreed that allowing the U.S. Preventive Services Task Force this authority violated the appointments clause of the Constitution, which specifies that people using government powers must be “officers of the United States.” In this case, O’Connor ruled that U.S. Preventive Services Task Force members do qualify as officers, but their appointment is unconstitutional because they are not appointed by the President and confirmed by the Senate.
This paves the way for the repeal of Section 2713 and allowing insurers to decide what, if any, preventive care would remain free to patients in their plans. He also argued that because the ACA “force[s] Braidwood to [cover] services to which it holds sincere religious objections … offering coverage is itself a tacit endorsement of the behaviors that [the plaintiff] believes the services encourage.”
Losing access to preventive care
PrEP is a major component of the prevention pillar of the United States’ “Ending the HIV Epidemic” initiative and has successfully reduced HIV diagnosis rates in areas where it is highly used. If this ruling were to extend nationally, over 170,000 current PrEP users and over 1 million people who can benefit from this medicine could be affected.
PrEP is a key tool to helping the U.S. reach its goal of substantially reducing new HIV infections by 2030. AP Photo/Pablo Martinez Monsivais
Removing the cost barrier to PrEP made it more accessible with commercial insurance, the primary source of health coverage for over two-thirds of the population under age 65. Raising the cost barrier again would disproportionately harm younger patients, people of color and those with lower incomes. Black men who have sex with men could be particularly affected because of the structural barriers they face, despite having no more “risky” sexual behavior on average than other men who have sex with men.
What’s next?
For now, the religious freedom portion of the ruling is specific to PrEP and Braidwood Management’s purchase of plans that cover PrEP. It is unclear whether the order will apply only to these plaintiffs or nationwide.
The next filings, where both sides will begin to provide more information on how they believe the ruling should be applied, are due by Sept. 16, 2022. As of yet, there is no timeline for a concrete decision.
For the time being, access to PrEP, contraception, cancer screenings and all other forms of preventive care made free by the ACA continue to be available. Regardless of O’Connor’s final decision, this case seems likely to be appealed to the Supreme Court, where another showdown over the fate of a substantial part of the ACA will be decided.
Portions of this article originally appeared in previous articles published on Sep. 7, 2021 and Dec. 1, 2021.
Authors
1.Paul Shafer
Assistant Professor of Health Law, Policy and Management, Boston University
2.Kristefer Stojanovski
Research Assistant Professor of Social, Behavioral and Population Sciences, Tulane University
Disclosure statement
Paul Shafer has received funding in the past three years from the Commonwealth Fund, Arnold Ventures, Robert Wood Johnson Foundation, Kate B. Reynolds Charitable Trust, Starbucks Coffee Company, and Renova Health.
Kristefer Stojanovski has received funding in the past from the Robert Wood Johnson Foundation, the National Institute of Minority Health & Health Disparities, the National Institute of Mental Health, and the Fulbright Program
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Boston University provides funding as a founding partner of The Conversation US.
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