Sibylla Bostoniensis

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Hey, Americans and other people stuck in the American healthcare system. It's open enrollment on the state exchanges, and possibly through your employer, so I wanted to give you a little heads up about preventive care and shopping for a health insurance plan.

I've noticed from time to time various health insurance companies advertising themselves to consumers by boasting that their health plans focus on covering preventive care. Maybe they lay a spiel on you about how they believe in keeping you healthy rather than trying to fix problems after they happen. Maybe they point out in big letters "PREVENTIVE CARE 100% FREE" or "NO CO-PAYS FOR PREVENTIVE CARE".

When you come across a health insurance product advertised this way, promoted for its coverage of preventive health, I propose you should think of that as a bad thing.

Why? Do I think preventive medicine is a bad thing? Yes, actually, but that's a topic for another post. For purposes of this post, no, preventive medicine is great.

It's just that it's illegal for them not to cover preventive care 100% with no copays or other cost-sharing.

Yeah, thanks to the Obamacare law, the ACA, it's literally illegal for a health plan to be sold on the exchanges if it doesn't cover preventive care 100% with no cost-sharing, and while there are rare exceptions, it's also basically illegal for an employer to offer a health plan that doesn't cover preventive care.

They can't not, and neither can any of their competitors.

So any health plan that's bragging on covering preventive care? They're bragging on doing something that

1) Literally every health plan does,

2) They are forced to do by the government, and

3) Which is the absolutely most bottom-of-the-barrel, basic requirement on a health plan to be legal to sell.

So any health plan that does this? They are trading on your ignorance. They think you're a schmuck. They're playing you for a sucker and easily led.

Insofar as they are insinuating their plan does something other companies' plans don't, they're 1) slandering their competitors and 2) lying that they're providing something special.

Advertising "Our ACA plan has free preventive care!" is like a landlord advertising, "Our apartments are up to code!" or an automotive manufacturer advertising, "Our cars come with a free set of brakes pre-installed!" One can infer from this maneuver that they haven't got anything better about their plan to advertise, so they're putting lipstick on their pig.

Given that, it's legit to start worrying just what's wrong with their health plan that they're trying to present clearing one of the lowest legal bars of ACA compatibility as some sort of competitive advantage.

Or maybe there's nothing actually wrong with the health plan itself, but you're left with the fact the health plan is apparently managed by the kind of people who would engage in such advertising. The kind of people who think the way to promote their product is with deception. The kind of people who think the right approach to getting customers is to trick them into buying their product.

They are, let us say, not starting out in a way that suggests they mean to proceed honorably and with transparency. It doesn't suggest they regard their customers with respect. It doesn't suggest they expect to be subject to the scrutiny of knowledgeable health insurance shoppers – thereby raising the question of what they intend to hide.

Now, I'm not suggesting that bragging on preventive care coverage should be a kiss of death. But I do recommend factoring it in. If you're looking at a plan which is much cheaper in its monthly premium than others and it's touting its preventive care coverage, that's a pretty clear sign the plan has absolutely nothing to recommend it aside from price. It has no bells, it has no whistles. It probably has a physician network that could fit in a Starbucks, one in-network hospital with a complimentary mold infestation, and a deductible that is eye-watering. The wait times for customer service will likely be compatible with reviewing major motion pictures and when you finally are connected the agents will be audibly dead inside. But hey: cheap!

Maybe that's what works for you. Your call. No judgment from me. I just want you to know what that kind of advertising portends.

Now, it's important to remember, like I explained previously, "preventive care" is an improper noun: it does not mean what the words say. When used in a health insurance context (which these days has pretty much engulfed all other health care contexts) it definitionally means Things On The Official List of Preventive Care. Actually preventive care that's not on the Official Preventive Care List isn't preventive care. MRI to check for lung cancer because you used to smoke? Preventive care. MRI to check for lung cancer because you used to work in an asbestos factory? Not preventive care, you're gonna have to pay for all or some of it.

So, should it ever happen that a health plan advertises to you that they cover preventive care beyond what the ACA mandates – I've never seen this happen, but I suppose it's theoretically possible – that would be actually interesting. I would still be suspicious they were up to no good, but would need to look into the details to decide if it was a con. Like if a plan advertises, "The government says we need to cover mammograms from age 40. We decided to cover them from age 30!" that sounds nice, but, I dunno about you, myself, I have never been champing at the bit to get more mammograms than I strictly need to. It seems like a safe bet to offer free early mammograms to anyone who wants one because that's probably gonna be a mighty small pool of takers in exchange for a lot of good vibes. "Check it out, my health insurance is willing to cover my getting a mammogram already! It's nice to see a company that actually cares about women's health!" "That's so cool! So have you booked one?" "What? No, of course not. I'm only 30. I hear they put your tit in a vise, and there's, like, radiation and stuff. Ew. No."

And that's if they even offer to do it with no cost-sharing. Plenty of insurances are happy to assure you, "We cover X", while meaning, "We cover X, at all, which is to say partially, and then only after you meet your deductible." Which is to say they cover some of X if you've already paid out of pocket for Y and Z and A, B, and C.

But I must allow: I can imagine a plan earnestly advertising actually desirable preventive care that the ACA doesn't mandate. I know an employer plan that covers the Grail (Galleri cancer screening) test, which most definitely is not on the ACA list and most insurance don't cover, and that's about $1k out of pocket; advertising that would be legit. "We cover all vaccinations, 100%, no cost-sharing, no prior auths, regardless of ACIP recommendation status, regardless of FDA approval status, no questions asked." Yeah, that could be pretty cool. "One whole-genome DNA test, free, per insured." Actually intriguing.

So with that said, anybody advertising to you that "preventive care", in so many words and otherwise unspecified, is wholly covered?

Personally, I think that's a company you should trust, oh, 10% less than you usually would.

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Loose change thoughts:

1)

You'll have noticed I keep using the word "cost-sharing" here. It is a very powerful term. One of my favorites. It's the insurance industry buzzword for "all the ways insurance doesn't cover the things it covers." You know: like how your insurance will say, "Sure, that doctor's appointment is covered, but you still have to pay a co-pay" or "Sure, that doctor's appointment is covered - after your deductible" or "Sure, that doctor's appointment is covered, but you have to pay 20% co-insurance". "Cost-sharing" is all the healthcare expenses your insurance sticks you with despite ostensibly insuring your health.

Yeah, it figures that the insurance industry would have had to come up with some decorous, concise euphemism for all that.

Cost-sharing doesn't include the premium (the price per month for the plan) or the amounts you pay because they just flat out won't cover something because the provider was out of network or the procedure didn't have a prior approval or because they've decided that body part is optional or because their formulary requires "step-therapy" or because they hate the ordering physician's tie or because it's a day ending in Y. The reason it's called "cost-sharing" is because it's when you are on the hook to pay a share of what otherwise they would pay for.

The idea behind cost-sharing is that the patient has to have some economic skin in the game or otherwise the patient will go, "Whoohoo! Free healthcare! I could get everything that ails me treated!" and go rack up huge medical bills for the insurance to pay. With cost-sharing, see, patients are discouraged from using too much healthcare unless they're rich.

So another way to think of cost-sharing is "insurance bullshit fees". As in "preventive care is required to be covered without any insurance bullshit fees." It's doesn't look at first glance like a terribly precise synonym, but it's surprisingly effective communication. Like if I say, "all that said, the ACA allows insurance companies to charge insurance bullshit fees for preventive care if it's out of network", you now know exactly what that means, right? It's way more transparent than "cost-sharing". But since the insurance industry and the government will continue to use the term "cost-sharing", you can now mentally pop that replacement in to orient yourself to what's being said.

2)

When I was writing this, checking my facts, I actually turned up the Official What The ACA Requires Health Insurance To Cover Meta List, as of 2022 – i.e. from before the US made the next most recent step in going further haywire. It says:

Private Health Coverage

Under the ACA, most private insurance plans are required to cover four categories of preventive services in-network without cost-sharing, including:

1. evidence-based preventive services that have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force (USPSTF), which indicates moderate to high certainty that the net benefits of those services are moderate to substantial;¹

2. routine vaccines for adults and children that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) and which has been adopted by the Director of the Centers for Disease Control and Prevention (CDC);²

3. evidence-informed preventive services for infants, children, and adolescents provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA);^†,3 and

4. preventive care and screenings for women, other than those that have in effect a rating of A or B in the current recommendations of the USPSTF, that are provided for in comprehensive guidelines supported by HRSA.⁴ These requirements do not apply to grandfathered plans, which are plans that existed on March 23, 2010, before the law was enacted, that meet certain requirements, and that are exempt from certain provisions of the ACA.^‡

The range of preventive services covered without cost-sharing includes services such as alcohol misuse screening and counseling, blood pressure screening, depression screening, immunizations, and obesity screening and counseling. Certain covered preventive services recommended by the USPSTF are specific to people in certain age groups or individuals at increased risk; for example, screening for latent tuberculosis in populations at increased risk of infection, and colorectal cancer screening for adults aged 45 to 75.^5,6,7 The USPSTF defers to the ACIP on recommendations concerning the use of vaccines.

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† The guidelines implemented by HRSA are commonly referred to as Bright Futures and the Women’s Preventive Services Guidelines.
‡ These requirements also do not apply to coverage of certain services when a religious exemption applies.
§ The Centers for Disease Control and Prevention (CDC) sets the U.S. adult and childhood immunization schedules based on recommendations from the ACIP.

[...]

References

1. The Patient Protection and Affordable Care Act, Sec. 2713 (a)(1)
2. The Patient Protection and Affordable Care Act, Sec. 2713 (a)(2)
3. The Patient Protection and Affordable Care Act, Sec. 2713 (a)(3)
4. The Patient Protection and Affordable Care Act, Sec. 2713 (a)(4)
5. U.S. Preventive Services Task Force. Latent Tuberculosis Infection: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/index.php/recommendation/latent-tuberculosis-infection-screening
6. U.S. Preventive Services Task Force. Colorectal Cancer: Screening.
https://www.uspreventiveservicestaskforce.org/uspstf/index.php/recommendation/colorectal-cancer-screening
7. Centers for Medicare & Medicaid Services. Preventive care benefits for adults. https://www.healthcare.gov/preventive-care-adults

As you can see, this is not a comprehensive list of what is and is not covered for whom by "preventive care". But it is a map of power relations, showing who and what has authority over what parts of the list.

For example, those of you who were paying attention back in September to the mess made of Covid vaccination may recall that it had something to do with ACIP. Yeah: among other things, the ACA says preventive care has to be covered without cost-sharing, and, like this document says, the USPSTF gets the authority to say what's preventive care, except for vaccines, which the USPSTF defers to the CDC to determine, which authority the CDC delegates to ACIP to determine. ACIP's recommendations of vaccinations, become the CDC's recommendations of vaccinations, which become the USPSTF's recommendations of vaccinations, which become the USPSTF's recommendations of vaccinations, which then are the ACA's recommendations of vaccinations, and the ACA says insurance has to pay for recommended vaccinations. Thus ACIP's recommendations of vaccinations have the force of law – the ACA – over your insurance company, as something they have to pay for, and, hooboy, is there a post or three in that topic.

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