Health Plan Weekly

On March 30, 2023, Judge Reed O’Connor in the U.S. District Court in the Northern District of Texas issued a ruling in the case, Braidwood Management Inc. v. Becerra, striking down the Affordable Care Act’s coverage requirement for certain preventive services with zero cost sharing. O’Connor ruled that the federal government cannot require health plans to cover services recommended by the U.S. Preventive Services Task Force (USPSTF) on or after March 23, 2010 — such as preexposure prophylaxis for HIV and screenings for HIV, cancers, suicide risk and hepatitis C. The Biden administration has appealed this decision to the Fifth Circuit Court of Appeals.

Since the 2010 passage of the ACA, millions of enrollees have used preventive services. In 2018, six in 10 privately insured people received some preventive care that’s subject to the ACA’s no-cost coverage mandate, with women, children and elderly adults more likely to use such care, according to a study published by the Peterson-KFF Health System Tracker. Another analysis by HHS’s Office of the Assistant Secretary for Planning and Evaluation estimated that about 151.6 million people had access to preventive care without cost sharing in 2020.

Federal remote monitoring regulations tied to the COVID public health emergency (PHE) are expiring soon, and insurers and providers must make sure that remote monitoring is being used effectively and in compliance with permanent regulations. Health care experts say that payers and providers have an opportunity to improve clinical outcomes and increase value by applying pandemic-era lessons learned and best practices to ongoing remote monitoring-assisted care.  

Remote patient monitoring became a vital tool for practitioners during the COVID-19 pandemic’s darkest days. Hospitals were overwhelmed and, in many places, barred from providing elective services, creating an urgent need for “hospital-at-home” care. The Biden and Trump administrations facilitated expanded use of remote monitoring technologies through emergency regulations tied to the duration of the PHE, but it is set to end on May 11. In particular, hundreds of emergency use authorizations (EUAs) from the FDA will expire unless they have undergone a review process. Going forward, some reimbursement codes set up by CMS during the pandemic will be phased out, and others will carry on until the agency can set up permanent protocols.   

On April 18, the U.S. Supreme Court will hear oral arguments in a case that has major implications for government contractors, including health insurers, which are generally subject to a host of complicated regulations and can face federal fraud allegations for knowingly violating those rules. 

Major insurer trade group AHIP recently teamed up with the American Hospital Association (AHA) to file an amicus brief arguing that a ruling in favor of the government’s position in two consolidated cases — U.S. ex rel. Schutte v. SuperValu Inc. and U.S. ex rel. Proctor v. Safeway, Inc. — “would create a Wild West of ramifications for any well-intentioned and legitimate hospital or insurance provider that seeks to serve Americans in partnership with the government.”  

During a recent panel discussion featuring equities analysts who cover the health care sector, analysts expressed skepticism that the rapid rate of mergers and acquisitions occurring in the industry will slow down in the near future — and they suggested that may not be such a bad thing. 

“Can I just say no?” George Hill, a managing director at Deutsche Bank, said when asked whether tougher antitrust enforcement is having an impact on health care consolidation. Hill was one of four equities analysts who discussed market trends shaping the health care system during the USC-Brookings Schaeffer Initiative for Health Policy’s 27th “Wall Street Comes to Washington” roundtable.