The Effect of Free Provision of Preventive Care under ACA on Prevention Utilization: Evidence from Commercial Health Plans

Introduction: Starting September 23^rd 2010, the Affordable Care Act (ACA) requires most health plans to cover certain preventive health services at no cost to beneficiaries, i.e. no copayment or co-insurance, and without having to meet deductible requirement. The law, by enhancing the affordability and accessibility of preventive care, aims at encouraging people to use more preventive services making them healthier and thus helping reduce the health care costs in the long run. To examine the effectiveness of the reform, we begin by exploring people’s response to the free provision of preventive services. In particular, we examine how the ACA changed the pattern of use of preventive services in the US.

Methods: Data are from the 2007-2011 Truven MarketScan Commercial Claims and Encounter Data. We focus on four preventive services (i.e. flu shots, mammography screening, office visits for preventive care by new and existing patients) and five health plans (i.e. HMO, POS, PPO, CDHP, HDHP). The total number of enrollees from 2007 to 2011 is 1,541,215,272, among which 70,214,387 received at least one of the four services over the five years. Our analysis sample consists of 14,675 state-plan-month observations for adults aged from 20 to 64 who are enrolled in the aforementioned five plans. We assess the effect of the reform on service-plan-specific utilization by comparing the pattern of use of preventive services before and after the reform and across health plans. Using a Difference-in-Difference approach, we show modest increases in rates of preventive services overall, with differences by plan type, service, and patient age.

Results: Our key findings are the following: (1) The reform significantly increased the utilization rates of all four preventive services (i.e. flu shots by 8.1%, mammography screening by 3.1%, preventive office visits by new patients by 6.9%, and preventive office visits by existing patients by 3.3%). Once we controlled for age-reform or age-plan interactions, the overall impact on service utilization became modest, especially for flu shots. (2) The reform increased the utilization rates of flu shots and mammography screening among enrollees in CDHP relative to PPO, but had no significant differential effect on office visits. (3) The utilization rate of flu shots went down by 7.8% among HDHP enrollees relative to PPO plans while no significant differential effects between the two plans were detected in other services. (4) In general, older people are associated with greater use of preventive services and are more likely to increase their utilization in response to the reform.

Discussion: After ACA’s expansion of coverage of preventive care, restrictive health plans show mixed evidence in the use of preventive services. This suggests that the pattern of changes in utilization of preventive services may reflect other factors including (1) unawareness of or lack of knowledge about free preventive care, especially among plans featuring high-deductibles, (2) insufficient response time by consumers, and finally (3) the health plans’ compliance with the law that may play a role in the full implementation of free provision of preventive care.