One welcome provision of healthcare reform embraces the adage that an ounce of prevention is worth a pound of cure. As of September 2010, new insurance plans (and some established ones) are offering participants a host of preventive health services at no additional cost, from cancer screenings and AIDS tests to counseling on diet and sexually transmitted diseases.
[Our Best Hospitals guide can help you find top-notch medical care.]
Previously, the rules about preventive coverage varied significantly by state and type of service, and they often required the policyholder to share the costs in the form of a copayment or a fee counted toward a deductible. While there are still limitations on who can get which services and how often (for example, only women ages 40 to 74 can receive free mammograms every other year), the law makes more accessible several dozen types of care that experts agree could save lives. "Preventive stuff gets kind of pushed to the side," says Jud Richland, president and CEO of Partnership for Prevention, a Washington, D.C.-based health research and advocacy group. "The hope is that by fully covering these things, over time delivery of these services becomes more top of mind."
The new law immediately affected plans created after March 23, 2010; insurers had to amend policies by September 23. Older plans have to include the required preventive services only when the administrator makes any other changes to existing coverage. Some employers have already taken the initiative to provide many of these services at no extra charge to their workers, and Medicare recipients also now can get a number of tests and vaccines at no additional cost. Consumers should note, though, that if their health plan mandates using a specific set of providers, then their costs are picked up entirely only when they visit a designated in-network facility or caregiver.
The current list of covered services is based on recommendations from the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the U.S. Preventive Services Task Force, an independent national panel of more than a dozen primary care and prevention experts. The task force evaluates medical research and assigns ratings to particular services based on their predicted benefits and potential risks for the patient. The list includes recommendations that infants, children, and adults be provided with the full schedules of CDC-endorsed immunizations, as well as services (such as blood pressure tests or certain cancer screenings) that receive an "A" or "B" task force rating, indicating that they will likely provide "substantial" to "moderate" benefits to the individuals being treated. Insurers are required to check the task force list annually and to include all "A" and "B" rated services in their coverage.
To find out which ones apply to you, check out the Department of Health and Human Services' Electronic Preventive Services Selector, which is available online or as a smartphone application. The selector retrieves a personalized list of task force-endorsed services based on your answers to five questions about your age and sex, and whether you smoke, are sexually active, or are pregnant. The list might go well beyond the typical fare of a standard physical. Adults who are concerned about possible alcohol abuse, obesity, or tobacco addiction, for instance, can seek free counseling.
One goal of the task force list is to steer consumers toward medical services of established value and away from tests and treatments whose effectiveness is unproven. "Where we lose is when people go out there and get things that are not recommended," says Virginia Moyer, chair of the task force and a professor of pediatrics at Baylor College of Medicine in Houston. Tests such as dementia screening and chest X-rays for lung cancer (for nonsmokers and asymptomatic smokers) that haven't yet shown substantial benefits sap medical resources, she says, and could even expose people to greater health risks such as excess radiation from certain imaging devices. And a false diagnosis could lead to more costly—and unnecessary—procedures or treatments.
Still, experts are more concerned about the number of tests Americans are not getting that could prevent serious illness and save lives. In 2008 (its most recent statistics), the CDC estimated that fewer than 25 percent of adults ages 50 to 64 were up to date with their colonoscopies, breast cancer screenings, and flu vaccines. Among people 65 and over, the record was somewhat better, but still only about 50 percent. Too many Americans wait until they're sick to seek medical attention, says Bryan Liang, executive director of the Institute of Health Law Studies at California Western School of Law in San Diego and a professor of anesthesiology at the University of California–San Diego School of Medicine. "We don't move until there's blood on the carpet," he says.
Now that cost has been removed as an excuse, here are some of the covered services Americans can—and should—get:
- Blood pressure screenings for adults age 18 and older every two years for those with normal readings and annually for those with elevated results.
- Cervical cancer screenings every three years for sexually active women.
- Child services, including screenings for autism at 18 and 24 months; iron supplements for children at 6 to 12 months who are at a greater risk for anemia; and at least one vision screening for children under age 5.
- Cholesterol screenings at least every five years for men age 35 and older and women age 45 and older. Additional screenings are covered for younger people at higher risk for heart disease.
- Colorectal cancer screenings of various types, including annual fecal occult blood testing and colonoscopies every 10 years for adults ages 50 to 75.
- Diabetes screenings every three years for adults with high blood pressure, even if they don't display symptoms of type 2 diabetes.
- Diet counseling by primary care physicians, nutritionists, or other specialists for all adults at risk for certain heart- or diet-related diseases. Coverage also extends to obesity screenings and counseling for all adults and children over 6.
- Evaluations for depression for people age 12 and older.
- Immunizations, including flu, hepatitis, human papillomavirus vaccine (for girls and young women ages 11 to 26), as recommended by the CDC. To find age-based schedules of covered immunizations, see the CDC's schedule.
- Mammograms for women ages 40 to 74 every two years. (The law goes beyond the task force recommendation to start at age 50.) Those at higher risk for breast cancer also can schedule a free consultation with their physician about the pros and cons of taking drugs that might reduce their chance of contracting the disease.
The entire list of copay-free services can be found at Healthcare.gov. Different carriers might have unexpected restrictions or qualifications in their guidelines for preventive services, cautions Sabrina Corlette, a research professor at Georgetown University's Health Policy Institute in Washington, D.C. For instance, a plan might not waive your copay if you happen to get a screening during a sick visit, Corlette says, because prevention wasn't the primary reason for going to the doctor. In addition, when the task force doesn't recommend a specific interval for a service, then the insurer is free to set its own. So consumers should check their individual policies each year to determine their coverage options.
Some experts worry that the new insurance provisions don't go far enough in encouraging people, particularly those at high risk for certain medical conditions, to seek these services. A study published in April by researchers at Boston University found that individuals who abuse alcohol, illegal drugs, or prescription medications are less likely to receive flu vaccinations and mammograms, for example. Offering additional incentives, like lower premiums for people who get screened and change their health habits, might be one way to help get them on board.
"We need to think really broadly," Moyer says, and not assume that insurance coverage "is the only answer." She and other experts believe that the government and the medical community need to better educate consumers. Preventive services represent only a fraction of the country's annual healthcare costs, but the returns can be enormous in time and money saved when diseases are caught or treated at earlier stages.