Evidence-Based Clinical Prevention in the Era of the Patient Protection and Affordable Care Act: The Role of the US Preventive Services Task Force

For more than 3 decades, the US Preventive Services Task Force (USPSTF) has made recommendations regarding clinical preventive services for asymptomatic adults and children in primary care, based on a rigorous analysis of the best available evidence. Members of the task force are experts selected from fields involved in preventive services for a broad range of health conditions encountered in primary care. A broader array of experts including disease specialists provided detailed peer reviews of task force evidence summaries and draft recommendations. The USPSTF has an interest in improving the health of the public and helping ensure access to preventive care.

In the last decade, the task force has increased efforts to enhance transparency, communications, and engagement with stakeholders, external scientists, and the public. The USPSTF approach aligns with the recommendations of the Institute of Medicine on using evidence from high-quality systematic reviews and maintaining strict conflict of interest standards.¹

The recommendations of the task force include a specific letter grade depending on the magnitude and certainty of net benefit (Table). In 2010, the Patient Protection and Affordable Care Act (ACA) created a link between USPSTF recommendations and various coverage requirements. The ACA specifies that commercial and individual or family plans must, at a minimum, provide coverage and not impose cost sharing for any evidence-based preventive services that receive a grade of A or B from the USPSTF. Medicare and Medicaid are excluded from this provision of the ACA. Some advocacy groups and others have frequently misinterpreted the ACA linkage as licensing the task force to explicitly recommend for or against coverage.

The task force maintains that the science on effectiveness of preventive services should help to inform coverage decisions. It also maintains that the linkage between USPSTF recommendations and the ACA coverage mandate sets a minimum standard for coverage of preventive services. The science on effectiveness—although foundational—is only one factor that needs to be considered in developing coverage policy.

Having insurance and a breadth of coverage affects patients’ use of preventive services.^2-4 Lawmakers provided a mechanism for prioritizing services for enhanced coverage by linking recommendations from the task force and from others (Advisory Committee on Immunization Practices, Bright Futures pediatrics recommendations, and Health Resources and Services Administration women’s preventive services guidelines) to coverage.

In this context, the task force interprets its role as focusing on evaluating the science supporting a preventive service—one of the several considerations in coverage. The task force understands that, in addition to the scientific evidence, insurance coverage decisions involve other important considerations, including preferences of patients, clinicians, consumers, communities, special populations, purchasers, and others.⁵ The resulting A and B recommendations are linked to coverage in the ACA and form the basis for the decisions of others about how to implement coverage consistent with the task force grade and the ACA (Table). The passage of the ACA has not influenced the methods or evidence thresholds the task force uses to assign an A, B, or any letter grade, nor does the task force consider coverage implications when making recommendations.

Conversely, for services graded other than A or B, the ACA does not prohibit full or partial insurance coverage. The law states that “nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by the Task Force.” Thus, payers can offer full or partial coverage for preventive services graded other than A or B. Patients and their clinicians may choose preventive services they deem appropriate, even those without A and B grades.

Some have misinterpreted task force grades of C or I as recommendations against screening or even against coverage. This is not the intent of the task force. A C grade is still a positive recommendation that recognizes small net benefit, and the task force recommends that clinicians offer C-rated services to patients after considering the presence of patient risk factors, patient preferences, local disease prevalence, and availability of services. Considering such factors is especially important when there is heterogeneity of risk for patients affected by a C recommendation and when the assessment of net benefit depends substantially on patient risk, values, and preferences. Similarly, an I grade, a declaration of insufficient evidence, is not a recommendation against coverage but rather a call for more research.

For some non-A and non-B recommendations, covering the service may be medically reasonable. However, the task force cannot and has never started by predetermining whether a service should be covered and then manipulating the science to reach a grade that would link to coverage. Payers currently have the latitude to cover such services using well-established procedures to assess coverage policy. Lawmakers also have the power to require coverage of selected non-A and non-B graded services.

Screening mammography in women in their 40s provides a case in point. The USPSTF found that screening mammography is beneficial for women between the ages of 40 and 49 years. The incremental benefit of starting before age 50 years is small, and the false-positives and unnecessary biopsies were significant. A woman who understands the harms but values any chance of reducing her risk of dying of breast cancer, no matter how small, should be able to make an informed decision to begin screening before age 50 years. The task force supports that individual decision, but understands that in the absence of coverage, fewer women will make that choice. However, the USPSTF cannot reinterpret the science and exaggerate the net benefit simply to ensure coverage. Payers, however, have the option of providing coverage (as many do). Lawmakers have the option of requiring coverage for mammography (as they have done in the past).

In essence, the ACA leaves discretion to payers regarding coverage for non-A and non-B graded services—as was the case for all preventive services before the ACA. The law adds a “shortcut” to first-dollar coverage for A and B graded services only, leaving discretion to payers for other services. The net result is that implementation of the task force recommendations, as well as recommendations by other designated organizations, should lead to expanded access to highly effective, evidence-based preventive services.

The USPSTF supports improved access to effective preventive services. Although the ACA has provided an opportunity to link evidence to coverage for the most highly recommended services, these A and B recommended services are a floor, rather than a ceiling, on coverage of preventive services. The USPSTF is committed to using the best science to identify the most effective preventive services to improve the health of the public.

Corresponding Author: Albert L. Siu, MD, MSPH, Mount Sinai Medical Center, One Gustave L. Levy Place, PO Box 1070, New York, NY 10029 (albert.siu@mssm.edu).

Published Online: September 30, 2015. doi:10.1001/jama.2015.13154.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Information—Collaborators: Members of the United States Preventive Services Task Force include: Albert L. Siu, MD, MSPH (Chair): Icahn School of Medicine at Mount Sinai; Kirsten Bibbins-Domingo, PhD, MD (Vice Chair): University of California, San Francisco; David Grossman, MD, MPH (Vice Chair): Group Health Research Institute; Michael LeFevre, MD MSPH (Immediate Past Chair): University of Missouri; Linda C. Baumann, PhD, RN, APRN: University of Wisconsin; Karina W. Davidson, PhD, MASc: Columbia University; Mark Ebell, MD, MS: University of Georgia; Francisco Garcia, MD, MPH: Pima County Health Department; Matthew W. Gillman, MD, SM: Harvard University; Jessica Herzstein, MD, MPH: Independent Consultant in Occupational, Environmental, and Preventive Health; Alex R. Kemper, MD, MS: Duke University; Alex H. Krist, MD, MPH: Virginia Commonwealth University; Ann E. Kurth, PhD, RN, MSN, MPH: New York University; Douglas K. Owens, MD, MS: Stanford University; William R. Phillips, MD, MPH: University of Washington; Maureen G. Phipps, MD, MPH: Brown University; Michael P. Pignone, MD, MPH: University of North Carolina.