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PrEP and Reed O'Connor's ACA Ruling

A Texas judge ruled that the government could not compel private insurance companies to cover the costs of PrEP, a medication that can greatly reduce the risk of HIV infection. The ruling was based on the argument that PrEP is not "medically necessary" for people who are not already HIV-positive. However, many experts believe that this ruling could ultimately hamper efforts to prevent new infections.

In the CareTalk episode, "Preventative Care After the PrEP Ruling," hosts John Driscoll and David Williams discuss the broader implications the ruling could have on preventative care. Is it a big deal or is it a nothing burger?

What is PrEP?

Pre-exposure prophylaxis, also commonly known as PrEP, is a medical treatment that is used to prevent the contraction of certain infectious diseases. While it has traditionally been used to reduce the risk of HIV infection in high-risk populations, PrEP has recently been shown to be effective in preventing other serious infections as well. This makes it a crucial tool for healthcare providers looking to reduce the risk of disease transmission.

The mechanism behind PrEP is relatively simple. The medication works by blocking specific proteins that are involved in viral replication and entry into host cells. By targeting these proteins, PrEP essentially blocks the infectious agent from ever infecting host cells or reproducing itself in the body. As such, this treatment can help to eliminate the risk of developing an infection even before any symptoms become apparent.

Given its many benefits, it is not surprising that PrEP has become increasingly popular in recent years among both healthcare providers and individuals at higher risk of contracting viruses or parasites. It is an important tool in combating serious infectious diseases, and promises to improve public health by reducing transmission rates and helping people live longer, healthier lives. Thus, it is clear why pre-exposure prophylaxis is one of the most important breakthroughs in modern medicine today.

Is PrEP Covered by Insurance?

It is a well-known fact that pre-exposure prophylaxis, or PrEP, can be an incredibly effective tool in preventing the transmission of HIV. Despite its effectiveness, however, insurance coverage for PrEP remains inconsistent and unclear. On one hand, some private health insurers offer coverage for PrEP on par with other medications used to treat long-term medical conditions like diabetes and high blood pressure; on the other hand, public health insurance programs such as Medicaid have been more reluctant to provide coverage for the drug.

Texas Judge Rules Government Can’t Compel PrEP Coverage Under ACA

"In the shroud of looking after religious freedom (which preventive healthcare doesn't really have anything to do with) and with the patina of anti-gay activity and sort of sexual prudishness that would sort of suggest something from another century, the conservative attack dogs of the legal bar are really starting to chop and chip at the administrative state. By attacking preventive care and claiming that they're worried about religious alternatives, what they're really doing is reducing the scope of preventive care." - John (CareTalk)

"It matters because there's about 150 million people who are covered under plans that follow the ACA mandates, and that includes preventative care. The idea is basically rather than waiting for someone to get HIV and then treating it, you give the same medication to people that are at very high risk of HIV, so that could be men who have sex with men, it could be sex workers, and it's covered now by the Affordable Care Act. And guess what? It turns out it's 99% effective in preventing HIV and it's just a pretty good payoff considering that it's thousands of dollars a year, but the impact is really great on an individual and even from a cost standpoint.

Preventative care, more broadly the Affordable Care Act, covers things like cancer screening, so that'd be colonoscopy and mammograms. It also covers smoking cessation, which is a big deal, alcohol abuse counseling, and the list goes on for preventive treatments. And so there has been a major expansion of preventive treatment under the Affordable Care Act that's covered with no copays. This did not use to be the case. It's a big deal from that standpoint if it affects prevention overall." - David (CareTalk)

Who is Judge Reed O’Connor?

"US district judge Reed O'Connor is the same judge who, a couple years ago, ruled that the whole Affordable Care Act was invalid based on one point." - David (CareTalk)

What are Health Disparities and How Do Mandates Affect Them?

"As it relates to prevention, if you look at colonoscopies and mammograms, which are both cancer screening methods that are recommended for people in certain categories and certain age groups, there's a lower percentage of people who are on the more vulnerable populations, that includes racial minorities, lower socioeconomic status, sexual minorities tend to have less access, less use of these tools.

When there is a mandate in place, there's at least some impact to reducing the disparity, meaning the difference, that's not based on any good reason, disparities between white people especially and Black and Hispanics on this area. So, if you get rid of prevention, the mandates for prevention, you're going to exacerbate, you're gonna make the health disparities worse, and so that's another argument not to allow it to happen." - David (CareTalk)

Will This Case Make it to the Supreme Court?

"I think that this is likely to be challenged and appealed based on the kind of backward-looking aspect of this and how it might be used not just to shrink access to preventive and protective care around activities that in some cases are associated with illnesses related to sexual contact. I don't think anyone can predict what the Supreme Court's gonna do, other than it's gonna tend towards more of the social mandates of the conservatives that voted them into power, you know, the majority into power.

I'm nervous, David. I'm nervous for two reasons. One, I don't trust that they won't make the wrong decision based on kind of the way you and I might look at it, but I also think that they are beholden to the people who voted them in, and so even though it might be a stretch to tie this to a Constitutional Appointments Clause or some argument about religious freedom, this is a court that appears to be more focused on its cultural agenda than kind of careful legal analysis." - John (CareTalk)



CareTalk is the only healthcare podcast that tells it like it is. Join hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they provide an incisive, no B.S. view of the US healthcare industry.



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