June 4 is the 36th annual National Cancer Survivors Day.1 The key components of survivorship include prevention, surveillance, intervention, and coordination. Early detection of cancer is associated with improved outcomes and survival, and regular screening increases the chances of detecting certain cancers early. Organized cancer survivorship programs have made progress in extending survival after cancer diagnosis and treatment. Formed in 1984, the US Preventive Services Task Force (USPSTF) is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine that traditionally makes recommendations regarding clinical preventive services based on research evidence.2 Throughout the past 20 years, there has been at least one nurse on the panel at any given time. Each recommendation receives a rating that reflects the utility of performing that service and whether a particular screening changes or improves health outcomes. The Patient Protection and Affordable Care Act (ACA) of 2010 required both private insurers and Medicare to cover the costs of certain cancer screenings with no cost sharing by patients. Extent of coverage continues to vary state by state and may depend on private insurance companies, Medicaid, and other employee health plans. USPSTF must present an annual report to Congress that identifies gaps in the evidence base for clinical preventive services and recommends priority areas that deserve further examination. Subsequently, recommendations with demonstrated benefit are included in the ACA list of preventive services that must be covered.
Attack on prevention
In September 2022, in response to a class-action lawsuit filed against the US federal government and the Health and Human Services (HHS) Secretary, Judge Reed O'Connor of the US District Court for the Northern District of Texas issued a summary judgment ruling that the federal government could not lawfully require, under the mandate of the ACA in question, commercial health plans to cover certain preventive health services at no cost to patients.3 At the time, the ruling applied only to those employers who brought the suit, arguing that religious reasons precluded them from securing health plans for their employees that cover certain preventive services such as HIV preexposure prophylaxis and contraception. The judge indicated that the main reason for his ruling was that the ACA mandate violated the Appointments Clause of the US Constitution: that is, because USPSTF members are not appointed by the President and confirmed by the Senate, the judge argued that they are not officers of the US and cannot make decisions regarding the law. The judge stated that the HHS is not empowered to reject USPSTF recommendations: more specifically, policy protects the USPSTF from political pressure to ensure their recommendations are independent, and the HHS is therefore not able to ratify the panel's recommendations. In March 2023, the judge ruled that his prior decision applied nationwide, thereby moving to void the ACA prevention-centric mandate in question. If upheld, insurers could opt out and force consumers to pay part of the cost of preventive care, making these services inaccessible to millions—especially vulnerable populations that already experience marked health disparities. Among others, two affected services are cancer screenings and tobacco cessation services.
The Biden administration has appealed Judge O'Connor's decision and will likely request a stay of the decision. The judge is considering all options; the plaintiffs have asked for a universal remedy, which others oppose. Patient advocacy groups and medical organizations have urged the court to reject a universal remedy. One size does not fit all—especially when size is not the critical issue. If the court grants the stay, consumers will not see any impact until the conclusion of the legal process. Articles published by top news outlets such as The New York Times, National Public Radio, The Wall Street Journal, and the Associated Press offer more details for readers who are interested.
Most preventive services on the USPSTF list are comparatively inexpensive and cost effective. Consumers across all types of insurance plans have become accustomed to receiving certain preventive services without cost sharing, which is an incentive for people to enroll in health plans. A collaborative approach among government agencies, legislators, healthcare professionals, and community advocates can sustain preventive healthcare services for all Americans to improve healthcare outcomes. Health equity is a goal that requires strategic actions to counteract and minimize the negative influences of social determinants of health (SDOH) on overall health and well-being of vulnerable populations. One Healthy People 2030 objective related to SDOH is to “increase the proportion of adults who receive appropriate evidence-based clinical preventive services” (see Social Determinants of Health for the initiative's five SDOH domains).4 The baseline in 2015 was 8.5%; in 2018, the number went down to 6.9%. With a target goal of 11.5%, we are already going in the wrong direction.4 Is our society trying to send that number to zero?
Consider that certain cancers are preventable, and for June and every day, celebrate with persons who are survivors of cancer.
Jamesetta A. Newland, PhD, FNP-BC, FAANP, DPNAP, FAAN
Editor-in-Chief [email protected]
1. National Cancer Survivors Day. 2023. https://ncsd.org
2. United States Preventive Services Task Force.2023. https://www.uspreventiveservicestaskforce.org/uspstf/
3. Twinamatsiko A, Baron Z. Sweeping ruling blocks preventive services coverage requirements nationwide. Health Affairs Forefront. April 7, 2023. www.healthaffairs.org/do/10.1377/forefront.20230405.235446/