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Published online by Cambridge University Press: 30 December 2024
Braidwood Management, Inc. v. Becerra challenges the Affordable Care Act free preventive coverage guarantee. Community health centers serve over 30 million residents of medically underserved urban and rural communities. Their limited federal grant funding makes them reliant on insurance revenue for their operations, Medicaid and subsidized marketplace coverage in particular, both of which are implicated by the case. To understand these implications, we developed an analytic model that crosswalks the preventive services potentially affected by Braidwood and the preventive care that all health centers must furnish. Of the 193 preventive services now covered under the guarantee, only forty-eight would survive were the Braidwood plaintiffs to prevail. In underserved communities, health centers are a principal source of the nearly 150 affected services, as evidenced by the care they are required to furnish under federal law, the quality metrics they are expected to meet, and the health diagnoses and treatments identified in federal performance reporting requirements. Thus, the impact on access, quality, patient health, and health center finances and care capability will likely be substantial.
1 See, e.g., Preventive Services, Healthcare.gov, https://www.healthcare.gov/glossary/preventive-services/ [https://perma.cc/7BVV-ZVT8]; see also Hugh Rodman Leavell & E. Gurney Clark, Preventive Medicine for the Doctor in his Community 1-13 (McGraw-Hill, 3d ed. 1965); see also Ctrs. for Disease Control & Prevention, Picture of America: Prevention 1, https://www.cdc.gov/pictureofamerica/pdfs/picture_of_america_prevention.pdf [https://perma.cc/72F9-DFFJ] (last updated Apr. 6, 2017).
2 See Vaccines and Immunizations, World Health Org., https://www.who.int/health-topics/vaccines-and-immunization [https://perma.cc/P6VV-TQRA].
3 See Off. of the Assistant Sec’y for Plan. and Evaluation, Access to Preventive Services Without Cost-Sharing: Evidence from the Affordable Care Act passim (2022), https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf [https://perma.cc/ME4V-YNMM]; Shirley Musich, et al., The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures, 19 Population Health Mgmt. 389, passim (2016).
4 See Preventative Care, Off. of Disease Prevention & Health Promotion, https://health.gov/healthypeople/objectives-and-data/browse-objectives/preventive-care [https://perma.cc/WZ9Z-E5N8].
5 See, e.g., K. S. Joseph et al., Maternal Mortality in the United States: Recent Trends, Current Status, and Future Considerations, 137 Obstetrics & Gynecology 763, passim (2021); see also Eugene Declercq & Laurie Zephyrin, Commonwealth Fund, Maternal Mortality in the United States: A Primer passim (2020), https://www.commonwealthfund.org/sites/default/files/2020-12/Declercq_maternal_mortality_primer_db.pdf [https://perma.cc/KDG7-K77C].
6 See, e.g., Donna L. Hoyert, Nat’l Ctr. for Health Stat., Ctrs. for Disease Control & Prevention, Maternal Mortality Rates in the United States, 2021 passim (2023), https://stacks.cdc.gov/view/cdc/124678 [https://perma.cc/SGA6-GD3E]; see also Pregnancy Mortality Surveillance System, Ctrs. for Disease Control & Prevention, https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm#causes [https://perma.cc/9S69-HNGD] (last updated Mar. 23, 2023).
7 See Preventing Pregnancy-Related Deaths, Ctrs. for Disease Control & Prevention, https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html [https://perma.cc/G9YG-DY3Q] (last updated Apr. 26, 2023); see also High Blood Pressure During Pregnancy, Ctrs. for Disease Control & Prevention, https://www.cdc.gov/bloodpressure/pregnancy.htm [https://perma.cc/TS9C-V6QD] (last updated June 19, 2023); Nicholas P. Deputy et al., Prevalence and Changes in Preexisting Diabetes Among Women Who Had a Live Birth – United States, 2012—2016, 67 Morbidity & Mortality Wkly. Rep. 1201, 1202, 1205 (2018).
8 See Four in 5 Pregnancy-Related Deaths in the U.S. Are Preventable, Ctrs. for Disease Control & Prevention (Sept. 19, 2022), https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html [https://perma.cc/7PCL-FEWF].
9 See id.; Infant Mortality, Ctrs. for Disease Control & Prevention, https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm [https://perma.cc/P92M-MCQ8].
10 See generally Comm. on Future of Primary Care, Inst. of Med., Primary Care: America’s Health in a New Era 41 (Molla S. Donaldson et al. eds., 1996) (stating that primary care clinicians manage preventive care); Primary Care, U.S. Ctrs. for Medicare & Medicaid Servs., https://www.cms.gov/priorities/innovation/key-concepts/primary-care [https://perma.cc/P5PC-MMWW] (defining preventive care as component of primary care); Primary Care, HealthCare.gov, https://www.healthcare.gov/glossary/primary-care/ [https://perma.cc/GN3D-M5L8] (including prevention within a definition of primary care); see also Primary Care, Am. Acad. of Fam. Physicians, https://www.aafp.org/about/policies/all/primary-care.html [https://perma.cc/V4AG-VA64] (stating that disease prevention is included within primary care).
11 Leiyu Shi, The Impact of Primary Care: A Focused Review, 2012 Scientifica 1, 15 (2012).
12 See Nat’l Acad. of Scis., Eng’g & Med., Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (2021); U.S. Dep’t of Health & Hum. Servs., HHS is Taking Action to Strengthen Primary Care, 2-3 (2023), https://www.hhs.gov/sites/default/files/primary-care-issue-brief.pdf [https://perma.cc/PZ6B-AWMG].
13 Health Centers Then & Now, CHroniCles, https://www.chcchronicles.org/histories [https://perma.cc/39P3-F6EZ].
14 See Health Ctr. Program, Health Res. & Servs. Admin., 2022 Uniform Data System Trends 1 (2023), https://bphc.hrsa.gov/sites/default/files/bphc/data-reporting/2022-uds-trends-data-brief.pdf [https://perma.cc/64VN-RV22]; Press Release, U.S. Census Bureau, Growth in U.S. Population Shows Early Indication of Recovery Amid COVID-19 Pandemic (Dec. 22, 2022), https://www.census.gov/newsroom/press-releases/2022/2022-population-estimates.html [https://perma.cc/RL37-42RC].
15 See 2022 Health Center Data, Full 2022 National Report, Health Ctr. Program, Health Res. & Servs. Admin., tbls.3B & 4, [hereinafter 2022 Health Center Data], https://data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=Full&year=2022 [https://perma.cc/PW36-AM9W].
16 See, e.g., Leiyu Shu et al., Primary Care Quality: Community Health Center and Health Maintenance Organization, 96 S. Med. J. 787, 787-95 (2003); Julia Paradise et al., Quality of Care in Community Health Centers and Factors Associated with Performance, The Kaiser Comm’n on Medicaid & the Uninsured, The Henry J. Kaiser Fam. Found. 1, 1-12 (2013); Elizabeth Jacobs et al., Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services, 94 Am. J. Pub. Health 866, 866-69 (2004).
17 42 U.S.C. § 254b(k)(3)(G)(iii) (2018).
18 42 U.S.C. § 254b(b)(1)(A)(i)(III) (2018).
19 U.S. Gov’t Accountability Off., GAO- -23-106664, Health Centers: Trends in Revenue and Grants Supported by the Community Health Center Fund (2023), https://www.gao.gov/products/gao-23-106664 [https://perma.cc/C5CZ-467X].
20 2022 Health Center Data, supra note 21, at tbls.9D & 9E.
21 Sara Rosenbaum et al., Community Health Center Financing: The Role of Medicaid and Section 330 Grant Funding Explained, Henry J. Kaiser Fam. Found. (2019), https://www.kff.org/report-section/community-health-center-financing-the-role-of-medicaid-and-section-330-grant-funding-explained-issue-brief/ [https://perma.cc/UK4M-RMEM].
22 Celli Horstman et al., Community Health Centers Need Increased and Sustained Federal Funding, Commonwealth Fund (2023), https://www.commonwealthfund.org/blog/2023/community-health-centers-need-increased-and-sustained-federal-funding [https://perma.cc/BD32-3HTV].
23 42 U.S.C. § 254b–2(b) (2018).
24 Peter Shin et al., Community Health Center Funding Needed to Preserve and Sustain Critical Access to Nearly 31 Million Patients, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (Nov. 9, 2023), https://geigergibson.publichealth.gwu.edu/community-health-center-funding-needed-preserve-and-sustain-critical-access-nearly-31-million [https://perma.cc/J3ZC-CGWA].
25 Peter Shin, et al., Community Health Centers in Financial Jeopardy Without Sufficient Federal Funding, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (Jan. 17, 2024), https://geigergibson.publichealth.gwu.edu/community-health-centers-financial-jeopardy-without-sufficient-federal-funding [https://perma.cc/SDA3-9RCK].
26 Health Res. & Servs. Admin., supra note 20.
27 Medicaid & CHIP: Medicaid Expansion & What it Means for You, Healthcare.gov, https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/ [https://perma.cc/LK4A-VTLQ].
28 Sara Rosenbaum et al, Community Health Centers: Recent Growth and the Role of the ACA, Henry J. Kaiser Fam. Found. (2017), https://files.kff.org/attachment/Issue-Brief-Community-Health-Centers-Recent-Growth-and-the-Role-of-the-ACA [https://perma.cc/BE7T-LXZL]; 2022 Health Center Data, supra note 21, at tbl.4.
29 Health Insurance Coverage of the Total Population, KFF, https://www.kff.org/other/state-indicator/total-population [https://perma.cc/4M9R-BYBJ].
30 See, e.g., Jeanne S. Ringel et al., The Elasticity of Demand for Health Care: A Review of the Literature and Its Application to the Military Health System 29-31 (Monograph Reports, 2002); The Impact of Price on Take-Up and Use of Preventive Health Products, Abdul Latif Jameel Poverty Action Lab https://www.povertyactionlab.org/policy-insight/impact-price-take-and-use-preventive-health-products [https://perma.cc/2S3X-LXPV].
31 Rosenbaum et al., supra note 34.
32 Coverage of most forms of preventive care for traditional Medicaid adults is discretionary other than, for example, immunizations, and family planning. Alexandra Gates et al., Coverage of Preventive Services for Adults in Medicaid, Henry J. Kaiser Fam. Found. (Nov. 13, 2014), https://www.kff.org/medicaid/issue-brief/coverage-of-preventive-services-for-adults-in-medicaid [https://perma.cc/F9S8-7FXW].
33 2022 Health Center Data, supra note 21, at tbl.4.
34 Rosenbaum et al., supra note 34.
35 See Hannah Katch & Paul Van De Water, Medicaid and Medicare Enrollees Need Dental, Vision, and Hearing Benefits, Ctr. on Budget & Pol’y Priorities (Dec. 8, 2020), https://www.cbpp.org/sites/default/files/atoms/files/12-8-20health.pdf [https://perma.cc/L65A-B2GW]; see also 42 U.S.C. § 18022 (2022).
36 Braidwood Mgmt. v. Becerra, 627 F. Supp. 3d 624, 624 (N.D. Tex. 2022).
37 Cong. Rsch. Serv., LSB11040, Preventive Services Access on the Docket in Braidwood v. Becerra (2023).
38 Three Reactions to Braidwood v. Becerra, Harv. L. Sch. Petrie-Flom Ctr. (Apr. 3, 2023), https://blog.petrieflom.law.harvard.edu/2023/04/03/three-reactions-to-braidwood-v-becerra/ [https://perma.cc/CQ6F-CWPV].
39 See A & B Recommendations, U.S. Preventive Servs. Task Force (Sept. 2023), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations [https://perma.cc/HHJ7-A5BD]; Women’s Preventive Services Guidelines, Health Res. & Servs. Admin., https://www.hrsa.gov/womens-guidelines [https://perma.cc/27MP-RX7A] (last reviewed Dec. 2022); Bright Futures, Health Res. & Servs. Admin., https://mchb.hrsa.gov/programs-impact/bright-futures [https://perma.cc/QW4N-LCX2] (last reviewed Nov. 2023); Vaccine-Specific Recommendations, Advisory Comm. on Immunization Practs., https://www.cdc.gov/vaccines/hcp/acip-recs/recs-by-date.html [https://perma.cc/PD94-S3YX] (last reviewed Jan. 12, 2024).
40 Cong. Rsch. Serv., supra note 43.
41 Second Memorandum Opinion & Order on Remedies in Relation to Plaintiffs’ Motion for Summary Judgment, Braidwood Mgmt. v. Becerra, 666 F. Supp. 3d 613 (2023) (No. 4:20-cv-00283-O).
42 Kruitka Amin et al., Use of ACA Preventive Services Potentially Affected by Braidwood v. Becerra, KFF (May 25, 2023), https://www.kff.org/health-reform/issue-brief/use-of-aca-preventive-services-potentially-affected-by-braidwood-v-becerra/ [https://perma.cc/R4G7-693K].
43 Caitlin Murphy et al., Braidwood Mgmt. v. Becerra Could Eliminate Three Quarters of the Affordable Care Act’s Preventive Benefits for Women, Infants, and Children, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (June 8, 2023), https://geigergibson.publichealth.gwu.edu/71-braidwood-management-v-becerra-could-eliminate-three-quarters-affordable-care-acts-preventive [https://perma.cc/FE2C-4QNM].
44 Sara Rosenbaum & Caitlin Murphy, Insurance Claims Data Show that Millions of Americans Rely on the Affordable Care Act’s Free Preventive Coverage Guarantee for Critical Maternal, Infant, and Child Health Care, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (Sept. 27, 2023), https://geigergibson.publichealth.gwu.edu/insurance-claims-data-show-millions-americans-rely-affordable-care-acts-free-preventive-coverage [https://perma.cc/V3T9-6G87].
45 Federally Qualified Health Center (FQHC), Healthcare.gov, https://www.healthcare.gov/glossary/federally-qualified-health-center-fqhc/ [https://perma.cc/57MB-PY5L]; What is a Health Center?, Health Res. & Servs. Admin., https://bphc.hrsa.gov/about-health-centers/what-health-center [https://perma.cc/WT46-VHEP] (last reviewed May 2023); 42 U.S.C. § 254b (2003).
46 Sara Rosenbaum et al., Family Planning and Medicaid Managed Care Integration, Phase Two Report: Insights from the Field, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (Mar. 1, 2022), https://geigergibson.publichealth.gwu.edu/69-family-planning-and-medicaid-managed-care-integration-phase-two-report-insights-field [https://perma.cc/V9BF-6NSV].
47 2022 Health Center Data, supra note 21, at tbl.4.
48 Murphy et al., supra note 49.
49 Evan V. Goldstein, Community Health Centers Maintained Initial Increases in Medicaid Covered Adult Patients at 5-Years Post-Medicaid-Expansion, 58 Inquiry 1, 2 (2021).
50 Author calculations derived from Rosenbaum, supra note 27.
51 Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches, U.S. Dep’t of Health & Hum. Servs. (Aug. 19, 2022), https://aspe.hhs.gov/sites/default/files/documents/dc73e82abf7fc26b6a8e5cc52ae42d48/aspe-end-mcaid-continuous-coverage.pdf [https://perma.cc/2HXH-3LZ4]; Peter Shin et al., Updated Estimates Show That Medicaid Unwinding Threatens Health Center Capacity to Serve Vulnerable Patients, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (Nov. 9, 2023), https://geigergibson.publichealth.gwu.edu/updated-estimates-show-medicaid-unwinding-threatens-health-center-capacity-serve-vulnerable [https://perma.cc/3R28-YWCM].
52 Medicaid Eligibility, Medicaid.gov, https://www.medicaid.gov/medicaid/eligibility/index.html [https://perma.cc/9Q7D-PPG6].
53 See infra Table 1 Supplementary material: ACA Preventive Services Protected or Eliminated Under Braidwood.
54 See infra Table 2 Supplementary material: Community Health Center Provision of ACA-Protected Preventive Services.
55 Uses of Quality Measurement, Agency for Healthcare Quality & Rsch., https://www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/uses/index.html [https://perma.cc/DMT3-GY4J] (last reviewed June 2020).
56 See infra Table 3 Supplementary material: Community Health Center Patients Receiving Preventive Care Services Covered by the ACA Preventive Service Benefit and Identified as a Community Health Center Care Measure, by State.
57 State Profiles for Women’s Health: U.S. Women’s Healthcare Access & Utilization Data, KFF, https://www.kff.org/interactive/womens-health-profiles/united-states/healthcare-access-usage/ [https://perma.cc/KV37-79JA].
58 See Michelle Long et al., Women’s Health Care Utilization and Costs: Findings from the 2020 KFF Women’s Health Survey, KFF (Apr. 21, 2021), https://www.kff.org/womens-health-policy/issue-brief/womens-health-care-utilization-and-costs-findings-from-the-2020-kff-womens-health-survey [https://perma.cc/33KH-DDZR]; see also Preventive Care: A National Profile on Use, Disparities, and Health Benefits, P’ship for Prevention, (2007), https://search.issuelab.org/resource/preventive-care-a-national-profile-on-use-disparities-and-health-benefits.html [https://perma.cc/HR2L-6CW4].
59 Geetest Solanki & Helen Halpin Shauffler, Cost-Sharing and the Utilization of Clinical Preventive Services, 17 Am. J. Preventive Med. 2, 127-33 (1999).
60 See Kruitka Amin et al., Preventive Services Use Among People with Private Insurance Coverage, KFF (Mar. 20, 2023), https://www.kff.org/private-insurance/issue-brief/preventive-services-use-among-people-with-private-insurance-coverage/ [https://perma.cc/BW4Y-4BLB] (finding that 60% of privately insured individuals in 2018 reported receiving “some ACA preventive care” that year).
61 2022 Health Center Data, supra note 21, at tbl.4 row 8.
62 Id.
63 U.S. Ctrs. for Medicare & Medicaid Servs., R11057CP, Update to the Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) for Calendar Year (CY) 2022 (Oct. 22, 2021).
64 Sara Boden, Federal Shutdown Could Disrupt Patient Care at Safety-Net Clinics Across U.S., NPR (Sept. 29, 2023, 6:53 AM), https://www.npr.org/sections/health-shots/2023/09/29/1201738506/federal-shutdown-could-disrupt-patient-care-at-safety-net-clinics-across-u-s [https://perma.cc/DZC7-5ENG].
65 Peter Shin et al., supra note 57.
66 Id.
67 Community Health Centers in the Wake of Dobbs, Geiger Gibson Program in Cmty. Health, Milken Inst. Sch. of Pub. Health (July 22, 2022), https://geigergibson.publichealth.gwu.edu/community-health-centers-wake-dobbs [https://perma.cc/LAS2-YKRP].
68 Sara Rosenbaum, EMTALA Pregnancy Protections Versus State Abortion Bans: The Supreme Court Will Decide, Health Affs. Forefront (Jan. 9, 2024), https://www.healthaffairs.org/content/forefront/emtala-pregnancy-protections-versus-state-abortion-bans-supreme-court-decide.
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