The Affordable Care Act (ACA) requires insurers to cover certain services without charging patients out-of-pocket. These services include routine preventive care, such as wellness visits, immunizations, contraceptive services, and cancer and other disease screenings. In September 2022, a federal court ruled portions of the law's preventive services provision unconstitutional. If the court decision stands, it is unclear whether private insurers will continue to cover preventive services at no cost to enrollees.
In this brief, we use HCCI data to better understand the costs that enrollees might face if the preventive services mandate were struck down entirely. We find that spending on preventive services represents a small fraction of total health care spending, but that the prices that individuals could face for preventive services are quite high if cost-sharing is allowed.
Among ESI Enrollees, Total Spending on Preventive Services was $204 per Person, or 3.5% of Total Health Spending
In 2019, total spending on preventive services was about $204 per person. This represents 3.5% of total dollars spent on health care services over the year.
Figure 1. Total spending on preventive services represents 3.5% of total health care spending in ESI
Of the no-cost preventive services, cancer screening made up the largest portion of total spending (1.3%), followed by contraceptive services (0.7%), immunizations (0.5%), and wellness visits (0.5%) (Figure 1). The remaining 0.5% was spent on all other preventive services combined. The graph below shows the $204 cost broken down by service category.
Figure 2. Total Dollars Spent Per Person by Service Category, 2019
Per person spending on preventive services is low, but costs to individuals could be prohibitively high
As shown above, when total spending on ACA covered preventive services is averaged across all ESI enrollees, per person spending on those services is just over $200 per person. If cost sharing for these services is reinstated, however, what individuals pay for these services could be much higher.
Table 1 shows the average price of a few common preventive services. The average price indicates what people would pay if each service were no longer covered by insurance or if they used the service before they reached their plan's deductible. Table 1 illustrates that, although there are modest per person costs for preventive services when total spending is distributed across all enrollees, the prices that individuals face for these services could be much higher if they were no longer covered or subject to cost sharing. For example, the cost of a colonoscopy CPT code spread across the whole ESI population is $11 per person, but the average price of a colonoscopy for a person who receives the service is more than $1,400.
Table 1. Cost of Common Preventive Services
| Service | Total Spending across All Enrollees |
Average Price
(Amount individuals pay if service not covered or before deductible is met) |
| Colonoscopy (CPT 45380) |
$11 |
$1,444 |
| Mammography (CPT 77067) | 24 | 255 |
| Insertion of IUD (CPT 58300) | 2 | 213 |
| Flu Vaccine (CPT 90686) | 2 | 21 |
| Cholesterol Test (CPT 80061) | 2 | 15 |
Even if the September 2022 court ruling stands, and portions of the ACA preventive services provision is overturned, insurers may continue offering preventive services without out-of-pocket costs to patients. It makes good business sense to cover preventive care rather than pay for more expensive downstream treatments. At the same time, there may be preventive services for which insurers will reinstate cost sharing, which could affect health care costs and individuals' health outcomes. Studies show that even modest out-of-pocket costs can reduce the utilization of health care services. If individuals face out-of-pocket costs for preventive services, they may avoid routine health care, which could, in turn, have costly consequences.