"To overcome well-funded business interests and bureaucratic inertia, proponents of equitable prostate cancer screening coverage must essentially clear a high hurdle on a broken ankle," writes Ross E. Weber of the AACU.
Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or email@example.com for more information.
In recent years, urologists and patient advocates have promoted proposals to require insurers to cover prostate cancer screening without copay, coinsurance, or cost sharing. These efforts have borne fruit in Maryland and New York, where state laws now place prostate cancer screening on par with breast cancer screening when it comes to cost-free coverage.
It should come as no surprise that health insurance companies are fierce opponents of these campaigns. Chambers of commerce, too, vigorously oppose the benefit mandates that, in the short term, increase insurance premiums. What’s astounding, however, is that most state governments themselves tip the scales toward the defeat of new patient-centered coverage requirements in the form of “mandated benefit review” laws.
The National Conference of State Legislatures reports that at least 30 states have mandate review or mandate evaluation boards to analyze the cost-effectiveness of current and proposed health insurance coverage requirements (See table: Mandated Benefit Evaluation Laws). These entities, mostly comprised of regulators and economists, are expected to evaluate services recommended by physicians and wished-for by patients based on the proposal’s impact on an insurer’s bottom line. Additional criteria, according to a 2006 study, include social impacts, medical efficacy, political considerations, and quality-of-care impacts. The same study found that fewer than half of the mandated benefit review laws utilized “an ‘evidence-based’ policy approach by requiring consideration of the scientific literature on medical effectiveness.” These actuarial, rather than public health, recommendations undermine proposed services such as prostate cancer screening because the reviews will most certainly say that the new mandate will increase premiums and few politicians want to be accused of increasing health costs when their next election comes along.
Very few new mandated benefit review laws have passed since 2011, when the Affordable Care Act (ACA) largely tied coverage and cost-sharing requirements to the state’s Essential Health Benefits. Those ACA-imposed standards did not stop lawmakers in at least 3 states in 2021: Texas, Minnesota, and Colorado.
Texas has conducted retrospective benefit mandate reviews through the Department of Insurance; ie, after the law has been implemented, agency staff review how it has impacted premiums. This year’s legislation moves the process to the Legislative Budget Board and requires that the review be conducted during the legislative process, well before it becomes law (HB 2600). Minnesota would likewise tweak its current law by requiring the review to be requested before August 1 of the year prior to the legislative session during which is would be considered (SF 146).
Colorado is perhaps the most interesting example of mandated benefit review laws. The state had been an early adopter of the practice, dating back to 1992 when policymakers required proponents of a proposed mandate to assess its potential impact. Eleven years later, a commission was established to conducts its own reviews, but by 2017 that effort had been abandoned. For at least the last 2 years, legislators have attempted to re-impose a semi-independent process, largely at the behest of Governor Jared Polis. In an April 1, 2020, statement, the Democrat Governor called on lawmakers to create a process for actuarial reviews of benefit mandates, warning that without that review, "I will be disinclined to sign future legislation creating new insurance mandates."
The bill introduced this year would require a third-party contractor to conduct up to 5 reviews per year on benefit mandates being proposed through legislation. The review would have to be requested by the proposed bill sponsor and would cover costs for the first 5 years.
Opponents of the legislation asserted that “the emphasis on short term costs would overshadow the need to identify gaps in care” and failure in that area would lead to the escalation of health care disparities in communities of color.
Certainly, lawmakers must consider the fiscal impact of legislation based on several factors, including whether it will place an undue burden on employers and the economy. As it currently stands, more than half the states place their considerable influence toward questioning the importance of patient-centered, medically recommended services. To overcome well-funded business interests and bureaucratic inertia, proponents of equitable prostate cancer screening coverage must essentially clear a high hurdle on a broken ankle. Therefore, as these proposals are introduced in legislatures across the country, it is vital for the entire urologic community to stand up to make their voices heard.