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ACP advocates on behalf on internists and their patients on a number of timely issues. Learn about where ACP stands on the following areas:
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Could Potentially Result in Discriminatory Health Benefit
Policy Statement Approved by ACP Executive Committee, Board of
Regents on March 14, 2014
Statement attributable to:
Molly Cooke, MD, FACP
President of the American College of Physicians (ACP)
The Affordable Care Act requires that group and individual health
plans cover preventive services without cost-sharing, including
diagnostic screenings, immunizations, and services specific to
women's health. The preventive services in each coverage category
are selected based on clinical evidence, including those rated A or
B by the United States Preventive Services Task Force. The services
and items available in the women's health category are based on
recommendations from the Institute of Medicine.
The preventive services requirement has drawn controversy, as
some non-profit religious organizations and for-profit corporations
have argued that the law forces them to provide health services
that conflict with their religious or philosophical beliefs. In
response, the federal government issued an exemption process for
religious organizations to choose whether to cover contraceptive
services. Religiously-affiliated non-profit charities and health
providers may also be relieved from directly paying for
contraceptive services; in this case, the federal government
requires that the organization's health insurer reimburse such
services if they are used by plan enrollees to ensure that the
services can be accessed without cost sharing.
While these exemptions accommodate religious organizations and
religiously-affiliated non-profit entities, they do not extend to
for-profit employers. Dozens of lawsuits have been filed by
employers and sympathetic organizations arguing that exemptions
should be extended to for-profit corporations and other employers.
One notable case, Hobby Lobby v. Sebelius, is scheduled to be heard
by the U.S. Supreme Court beginning on March 25, 2014. The Court
will consider whether the preventive services benefit mandate
violates the Religious Freedom Restoration Act of 1993, "which
provides that the government 'shall not substantially burden a
person's exercise of religion' unless that burden is the least
restrictive means to further a compelling governmental interest,
allows a for-profit corporation to deny its employees the health
coverage of contraceptives to which the employees are otherwise
entitled by federal law, based on the religious objections of the
Roughly 50% of Americans receive health insurance benefits from
their employer.i The ACA seeks to enhance employer-based
insurance by creating an essential benefits package for small group
insurance plans; mandating coverage of evidence-based preventive
services; and levying a tax on larger employers that do not provide
comprehensive, affordable insurance to their employees. Benefit
mandates for employer-based health insurance are nothing new.
According to the National Conference of State Legislatures, there
are over 1,800 state laws that mandate coverage of specific medical
services and payment.ii One-third of states have over 40
laws that mandate health insurance benefits.iii For
instance, all states and the District of Columbia mandate
vaccinations for children entering childcare and schools. Nearly
all states allow vaccination exemptions for individuals based on
their religious beliefs, but twenty states allow individuals to
refuse vaccination based on personal beliefs.iv
A survey of pediatricians found that 74% reported "encountering a
parent that refused or delayed one or more vaccines" within a
12-month period.v Evidence also shows a connection
between personal belief exemptions and communicable disease
rates.vi One study found elevated levels of pertussis in
areas with a high population of children from families with these
exemptions, concluding that "geographic pockets of vaccine
exemptors pose a risk to the whole community."vii
Hypothetically, if coverage exemptions were granted to businesses,
employers with either religious or personal objections to vaccines
could deny coverage to such critical services, forcing employees to
pay out of pocket.
The expansion of evidence-based medical coverage exemptions
could create a slippery slope where an employer could claim an
exemption to not only preventive care, but also coverage of
essential health benefits such as mental health services or blood
transfusions. Further, expanding benefit exemptions to more
employers would enable them to make coverage decisions irrespective
of medical evidence or the objective recommendations of medical
experts such as the Institute of Medicine. The College reiterates
its position that health insurance plans must cover an essential
health benefit package as well as evidence-based preventive
services without cost-sharing. Protecting such a policy will ensure
that the currently insured and newly insured can receive
comprehensive, affordable care based on the best medical evidence
The ACA's essential health benefit requirements, premium rating
reforms, cost-sharing caps, and subsidies are efforts to address
not only uninsurance, but also underinsurance, i.e, health
insurance that covers a limited set of benefits and/or has
significant cost sharing.viii Prior to the ACA,
underinsurance was a substantial and growing problem. A 2009 study
estimated that 25 million insured people were considered
underinsured in 2007, a 60% increase over 4 years. The authors
reported that the underinsured faced burdensome financial stress
and medical care access problems and that improved benefit designs
that ensure affordability and comprehensiveness of health coverage
were needed.ix The underinsurance problem
disproportionately affects those with low socioeconomic status,
underscoring the affordability problem.x While it is
unlikely that the ACA will eliminate the underinsurance problem,
the law's health insurance market reforms and financial assistance
provisions will undoubtedly relieve some of the more pernicious
effects. The effectiveness of these safeguards would be undermined
if employers were exempt.
About the American College of PhysiciansThe American College of Physicians is the largest
medical specialty organization and the second-largest physician
group in the United States. ACP members include 137,000 internal
medicine physicians (internists), related subspecialists, and
medical students. Internal medicine physicians are specialists who
apply scientific knowledge and clinical expertise to the diagnosis,
treatment, and compassionate care of adults across the spectrum
from health to complex illness. Follow ACP on Twitter and Facebook.
David Kinsman, (202) 261-4554, firstname.lastname@example.org
i Kaiser Family Foundation. Health Insurance Coverage
of the Total Population. Accessed at http://kff.org/other/state-indicator/total-population/
ii National Conference of State Legislatures. State
Health Insurance Mandates and the ACA Essential Benefits
Provisions. January 2, 2014. Accessed at
iii California Health Benefits Review Program.
Interaction between California State Benefit Mandates and the
Affordable Care Act's "Essential Health Benefits." March 2012.
Accessed at http://chbrp.org/documents/finl-ehb-issuebrief-mar2012.pdf
iv Immunize.org. Personal belief exemptions for
vaccination put people at risk. Examine the evidence for yourself.
Accessed at http://www.immunize.org/catg.d/p2069.pdf
v American Academy of Pediatrics. Documenting
Parental Refusal to Have Their Children Vaccinated. Accessed at
vi ASTHO. Permissive State Exemptions Laws contribute
to Increased Spread of Disease. Accessed at
vii Omer SB, Enger KS, Moulton LH, Halsey NA, Stokley
S, Salmon DA. Geographic Clustering of Nonmedical Exemptions to
School Immunization Requirements and Associations With Geographic
Clustering of Pertussis. Am J Epidemiol.
2008;168(12):1389-1396. Accessed at http://aje.oxfordjournals.org/content/168/12/1389.full
viii Gold J. The ‘Underinsurance' Problem Explained.
Kaiser Health News. September 28, 2009. Accessed at
ix Schoen C, Collins SR, Kriss JL, Doty MM. How Many
Are Underinsured? Trends Among U.S. Adults, 2003 and 2007.
Health Affairs. 2008; doi: 10.1377/hlthaff.27.4.w298.
x Link CL and McKinlay JB. Underinsurance is as Big a
Problem as Uninsurance. New England Research Institute. Accessed at