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Preventive Care and Health Equity: The Educational Divide

Published online by Cambridge University Press:  30 December 2024

David Gartner
David Gartner*
Affiliation:
Arizona State University, Washington D.C., USA
*
Email: David.Gartner@asu.edu
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Abstract

The preventive services at the center of Braidwood Management, Inc. v. Becerra contribute to reducing inequities in life expectancy in the United States. Critical preventive are currently fully covered by insurance as preventive care under the Affordable Care Act. Reducing affordable access to such screenings and medicines is most likely to impact those with lower incomes and less education, and contribute to widening existing inequities in health outcomes.

Recent research has identified a large and growing mortality gap between those with and without college degrees. On average, individuals without college degrees are likely to die about 8.5 years earlier than those with such degrees. In recent decades, cancer death rates fell nearly two times faster among the college educated. Mortality from heart disease fell by nearly two-thirds among those with college degrees but by less than one-third for all others.

Disparities in life expectancy in the United States reflect the uneven progress against the leading causes of death among different populations. The Braidwood decision, if upheld, will raise the costs to patients for interventions that have contributed to recent gains in life expectancy. This Article analyzes the impact of Braidwood on preventive health interventions in the context of growing life expectancy gaps within the United States.

Keywords

Braidwoodpreventive carehealth equitylife expectancyheart diseasecollege degree
Type
Articles
Information
American Journal of Law & Medicine , Volume 50 , Issue 1-2 , July 2024 , pp. 121 - 127
Copyright
© 2024 The author(s). Published by Cambridge University Press on behalf of American Society of Law, Medicine & Ethics and Trustees of Boston University

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References

1 Final Judgment at 1, Braidwood Mgmt. v. Becerra, 666 F. Supp. 3d 613 (N.D. Tex. 2023) (No. 4:20-cv-00283-0) (“The U.S. Preventive Service Task Force’s (PSTF) recommendations operating in conjunction with 42 U.S.C. § 300gg-13(a)(1) violate Article II’s Appointments Clause and are therefore unlawful. Therefore, any and all agency actions taken to implement or enforce the preventive care coverage requirements in response to an ‘A’ or ‘B’ recommendation by the PSTF on or after March 23, 2010 are VACATED …”).

2 42 U.S.C. § 300gg-13(a) (2018) (“A group health plan and a health insurance issuer offering group or individual health insurance coverage shall at a minimum provide coverage for and shall not impose any cost sharing requirements for– (1) Evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force.”).

3 See 2024 Heart Disease and Stroke Statistics Update Fact Sheet: At-a-Glance, Am. Heart Ass’n (Jan. 24, 2024) [hereinafter Heart Disease Fact Sheet], https://www.heart.org/-/media/PHD-FIles-2/Science-News/2/2024-Heart-and-Stroke-Stat-Update/2024-Statistics-At-A-Glance-final_2024.pdf [https://perma.cc/5AK2-SQSZ] (“Cardiovascular disease (CVD), listed as the underlying cause of death, accounted for 931,578 deaths in the United States in 2021.”).

4 Jiaquan Xu et al., Ctrs. for Disease Control & Prevention, Nat’l Ctr. for Health Stats., Data Brief No. 456, Mortality in the United States, 2021, at 6 (2022), https://www.cdc.gov/nchs/data/databriefs/db456.pdf [https://perma.cc/E3AG-5FC6] (“In 2021, a total of 3,464,231 resident deaths were registered in the United States.”)

5 See Heart Disease Fact Sheet, supra note 3; Seth S. Martin et al., 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association, 149 Circulation e347, e348 (2024) (“Heart disease has been the leading cause of death in the United States since 1921.”).

6 See Heart Disease Fact Sheet, supra note 3 (“Between 2017 and 2020, 127.9 million US adults (48.7%) had some form of CVD.”).

7 See David A. Frank et al., Disparities in Guideline-Recommended Statin Use for Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and Gender: A Nationally Representative Cross-Sectional Analysis of Adults in the United States, 176 Annals Internal Med. 1057, 1057, 1064-65 (2023); Nat’l Ctr. for Health Stats., Ctrs. for Disease Control & Prevention, Health, United States Spotlight : Racial and Ethnic Disparities in Heart Disease (Apr. 2019), https://www.cdc.gov/nchs/hus/spotlight/HeartDiseaseSpotlight_2019_0404.pdf [https://perma.cc/7QVJ-VWZP]; Mariana Garcia et al., Cardiovascular Disease in Women: Clinical Perspectives, 118 Circulation Rsch. 1273, 1286-87 (2016).

8 See Anne Case & Angus Deaton, Accounting for the Widening Mortality Gap Between American Adults with and Without a BA 18 (Brookings Papers on Econ. Activity Conf. Draft, 2023), https://www.brookings.edu/wp-content/uploads/2023/09/1_Case-Deaton_unembargoed.pdf [https://perma.cc/S6D6-46SR].

9 Final Recommendation Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication, U.S. Preventive Servs. Task Force (Nov. 13, 2016), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication-november-2016 [https://perma.cc/RQR7-X8YT]. The USTPF 2022 Recommendation with a grade of “B” was “that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or ore CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater.” Final Recommendation Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication, U.S. Preventive Servs. Task Force (Aug. 23, 2022), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication [https://perma.cc/NSE5-FFYS].

10 42 U.S.C. § 300gg-13(a) (2018).

11 Off. of Health Pol’y, Assistant Secr’y for Plan. & Evaluation, Access to Preventive Services Without Cost-Sharing: Evidence from the Affordable Care Act, HP-2022-01, at 2 (Jan. 11, 2022). An estimated 151.6 million Americans are covered by private insurance with such preventive service coverage according to the Office of the Assistant Secretary for Planning and Evaluation within the U.S. Department of Health and Human Services. Id. The Braidwood decision applies to private health insurance plans but it also could impact coverage under Medicaid expansion since the Affordable Care Act requires states to cover “essential health benefits” including the same preventive services required of private insurance plans. Id.

12 William M. Schultz et al., Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions, 137 Circulation 2166, 2167 (2018).

13 See Roger Chou et al., Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: A Systematic Review of the U.S. Preventive Services Task Force, 328 JAMA 754, 755-56 (2022).

14 Id.

15 Lisa Catanese, Statins: Types, Uses, Side Effects, and Alternatives, Harv. Health Publ’g (Nov. 29, 2023), https://www.health.harvard.edu/diseases-and-conditions/statins-types-uses-side-effects-and-alternatives [https://perma.cc/T4FQ-6K55].

16 Chou et al., supra note 13, at 764 (highlighting the findings of statin trials on cholesterol reduction: “difference in LDL-C 14.2% in ALLHAT-LLT compared with 26% to 50% in other large primary prevention trials”).

17 Id. (“There was no clear evidence of a differential effect of statin therapy based on demographic or clinical characteristics for any outcome.”). The review also found “no differences in harms of statin therapy based on within study analyses stratified according to age, sex or race and ethnicity.” Id.

18 Marcin M. Nowak et al., Effects of Statins on All-Cause Mortality in Adults: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies, J. Clinical Med., Oct. 1, 2022, at 9.

19 Amri Matyori et al., Statins Utilization Trends and Expenditures Before and After the Implementation of the 2013 ACC/AHA Guidelines, 31 Saudi Pharm. J. 795, 797 (2023).

20 See Frank et al., supra note 7, at 1057 (finding lower statin use among a range of groups that were not explained by other factors: “Statin use disparities for several race-ethnicity-gender groups are not explained by measurable differences in medical appropriateness of therapy, access to health care, and socioeconomic status.”); see also Elizabeth A. Jackson et al., Is Race or Ethnicity Associated with Under-Utilization of Statins Among Women in the United States: The Study of Women’s Health Across the Nation, 43 Clinical Cardiology 1388, 1388 (2020) (“In this cohort of multiethnic women, rates of statin use among women who would benefit were low, with Black women having lower odds of statin use than White women.”); see also Dinesh K. Kalra, Bridging the Racial Disparity Gap in Lipid-Lowering Therapy, J. Am. Heart Ass’n, Jan. 5, 2021, at 1 (“Despite dyslipidemia being more prevalent in certain ethnic minorities, they are prescribed lipid-lowering therapy less frequently …”).

21 See Jared W. Magnani et al., Educational Attainment and Lifetime Risk of Cardiovascular Disease, 9 JAMA Cardiology 45, 45 (2023) (“Lower education was associated with lifetime CVD risk across adulthood; higher education translated to healthy longevity.”).

22 Joshua Jacobs et al., Prevalence of Statin Use for Primary Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity and 10-Year Disease Risk in the US National Health and Nutrition Examination Surveys, 2013 to March 2020, 8 JAMA Cardiology 443, 443 (2023) (“Among other factors, routine health care access and health insurance were significantly associated with higher statin use in Black, Hispanic, and White adults.”).

23 See Michael Dorsch et al., Effects of Race on Statin Prescribing for Primary Prevention with High Atherosclerotic Cardiovascular Disease Risk in a Large Healthcare System, J. Am. Heart Ass’n, Nov. 19, 2019, at 4-5.

24 Nicole Fusco et al., Cost-Sharing and Adherence, Clinical Outcomes, Health Care Utilization and Costs: A Systematic Literature Review, 29 J. Managed Care & Specialty Pharmacy 4, 10-11 (2023); Teresa Gibson et al., Impact of Statin Copayments on Adherence and Medical Care Utilization and Expenditures, Am. J. Managed Care SP11, SP11 (2006) (“Lower statin copayments were associated with higher levels of statin adherence.”); Pinar Karaca-Mandic et al., Association of Medicare Part D Medication Out-of-Pocket Costs with Utilization of Statin Medications, 48 Health Servs. Rsch. 1311, 1311 (2013) (“Greater [out of pocket] costs for statins are associated with reductions in statin utilization.”); Andrew Davis et al., A National Assessment of Medication Adherence to Statins by the Racial Composition of Neighborhoods, 4 J. Racial Ethnic Health Disparities 462, 462 (2017) (“In black and Hispanic neighborhoods, good adherence was associated with copays under $10, the use of 90-day refills, and payers other than Medicaid.”).

25 Xin Ye, Association Between Copayment and Adherence to Statin Treatment Initiated After Coronary Heart Disease Hospitalization: A Longitudinal, Retrospective, Cohort Study, 29 Clinical Therapeutics 2748, 2753-754 (2007).

26 Fatima Rodriguez et al., Association of Statin Adherence with Mortality in Patients with Atherosclerotic Cardiovascular Disease, 4 JAMA Cardiology 206, 206 (2019) (“[L]ow adherence to statin therapy was associated with a greater risk of dying.”).

27 Sarah C. Van Alsten & Jenine K. Harris, Cost-Related Nonadherence and Mortality in Patients with Chronic Disease: A Multiyear Investigation, National Health Interview Survey, 2000-2014, Preventing Chronic Disease, Dec. 3, 2020, at 5 (“For example, having a college degree or higher was inversely associated with both CRN [cost-related nonadherence] and mortality, such that adjustment would likely move estimates closer toward the null.”); see also Gibson et al., supra note 24, at SP16 (“Patients living in … areas with higher college graduation rates were more adherent to statins.”).

28 Sebastian Schneeweiss et al., Adherence to Stain Therapy Under Drug Cost Sharing in Patients with and Without Acute Myocardial Infarction, 115 Circulation 2128, 2129 (2007).

29 Id. at 2128; see Jonathan H. Watanabe et al., Association of Copayment with Likelihood and Level of Adherence in New Users of Statins: A Retrospective Cohort Study, 20 J. Managed Care & Specialty Pharmacy 43, 43 (2014); Karaca-Mandic et al., supra note 24, at 1311; Teresa B. Gibson et al., The Effects of Prescription Drug Copayments on Statin Adherence, 12 Am. J. Managed Care 509, 509 (2006); see generally Niteesh K. Choudhry et al., Full Coverage for Preventative Medications After Myocardial Infraction, 365 New Eng. J. Med. 2088 (2011).

30 Schneeweiss et al., supra note 28, at 2128.

31 See Choudhry et al., supra note 29, at 2088 (“Enhanced prescription coverage improved medication adherence and rates of first major vascular events and decreased patient spending without increasing overall health costs.”).

32 See Fusco et al., supra note 24, at 10; see also Praful Schroff et al., Vulnerabilities to Health Disparities and Statin Use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study, J. Am. Heart Ass’n, Aug. 2017, at 9.

33 Case & Deaton, supra note 8, at 2.

34 Id. at 18.

35 Id.

36 Id.

37 Id. at 14 (“The main driver of mortality declines since the 1970s has been falling mortality from cardiovascular disease, driven by reductions in smoking, and the use of hypertensives and statins.”).

38 Schultz et al., supra note 12, at 2167.

39 See Case & Deaton, supra note 8, at 20-21 (showing falling mortality rates for both American adults with and without a 4-year college degree from 1990 to 2010).

40 See id. (“The long-term decline [of cardiovascular mortality] … stopped falling altogether after 2010 for those without the degree.”).

41 Magnani et al., supra note 21, at 49.

42 Heval M. Kelli et al., Low Educational Attainment is a Predictor of Adverse Outcomes in Patients with Coronary Artery Disease, J. Am. Heart Ass’n, Sept. 3, 2019, at 9.

43 Id. at 5.

44 Rita Hamad et al., Educational Attainment and Cardiovascular Disease in the United States: A Quasi-Experimental Instrumental Variables Analysis, PLoS Med., June 25, 2019, at 2 (“Increased education was consistently associated with improvements in several cardiovascular risk factors: smoking, high-density lipoprotein, and depression.”).

45 Id. at 1.

46 Karen Huynh, Low Educational Attainment Linked to High CVD Risk, 14 Nature Revs. Cardiology 442, 442 (2017).

47 Schultz et al., supra note 12, at 2168.

48 Id. at 2168.

49 Id. at 2167-68.

50 See Hao Ma et al., Cardiovascular Health and Life Expectancy Among Adults in the United States, 147 Circulation 1137, 1137 (2023) (“Equivalently, participants with high CVH had an average of 8.9 more years of life expectancy at age 50 years compared with those with low CVH. On average, 42.6% of the gained life expectancy at age 50 years from adhering to high CVH was attributable to reduced cardiovascular disease death.”).

51 See Case & Deaton, supra note 8, at 14; see also Max Roberts et al., Contributors to the Black-White Life Expectancy Gap in Washington, D.C., Sci. Reps., Aug. 27, 2020, at 6 (finding that heart disease contributes more than any other cause of death in accounting for disparities in life expectancy).

52 Enrique Acosta et al., Cardiovascular Mortality Gap Between the United States and Other High Life Expectancy Countries in 2000-2016, 77 Js. Gerontology Series B: Psych. Scis. & Social Scis. S148, S151-53 (2022).

53 Anne Case & Angus Deaton, Without a College Degree, Life in America is Staggeringly Shorter, N.Y. Times (Oct. 3, 2023), https://www.nytimes.com/2023/10/03/opinion/life-expectancy-college-degree.html.

54 See, e.g., Steven H. Woolf, Falling Behind: The Growing Gap in Life Expectancy Between the United States and Other Counties, 1933–2021, 113 Am. J. Pub. Health 970, 972–75 (2023).

55 See Robert M. Kaplan et al., Educational Attainment and Life Expectancy, in Policy Insights from the Behavioral and Brain Sciences 189, 189 (Susan T. Fiske et al. eds., 2014) (“medical care only explains about 10% of the variance in health outcomes, whereas behavioral and social factors outside of health care explain 50%. Evidence suggests that educational attainment may be one of the strongest correlates of life expectancy. As a baseline cancer screening and optimizing established risk factors for premature death typically extend life expectancy by less than 1 year. In contrast, remediating health disparity associated with low educational attainment might enhance life expectancy by up to a decade.”).

56 See Case & Deaton, supra note 8, at 12.

57 See id. at 11.

58 See id.

59 See id. at 11-12.

60 See Hamad et al., supra note 44, at 14 (stating that higher levels of education were associated with higher BMI in both surveys).

61 See Dorien M. Kimenai et al., Socioeconomic Deprivation: An Important, Largely Unrecognized Risk Factor in Primary Prevention of Cardiovascular Disease, 146 Circulation 240, 244 (2022); see also Kelli et al., supra note 42, at 7-9.