The Year in Review: Legislative Activity and Prostate Cancer Coverage Mandates

Prostate cancer screening rates have declined since the 2012 U.S. Preventive Services Task Force recommendations against routine prostate-specific antigen (PSA) screening. Steeper declines have been observed among non-Hispanic Black men compared to non-Hispanic white men, a concerning trend since Black men are at much higher risk for prostate cancer. The factors related to screening avoidance are varied and complex, but lawmakers at the federal, state and local level made efforts in 2023 to remove cost-sharing as a barrier to PSA screenings.

Left out of the Affordable Care Act

Early detection saves lives for men with prostate cancer. Ninety-nine percent of men diagnosed with prostate cancer survive when disease is detected early. While men over age 50 with Medicare coverage are eligible for one PSA test and digital rectal exam per year, men in most states with commercial insurance coverage are liable for out-of-pocket costs, such as copays and coinsurance, that can pose barriers. Other barriers include lack of transportation, travel time to medical facilities, lack of knowledge of the guidelines and risks, and reluctance to visit physicians for regular well-visit screenings.

As part of the Affordable Care Act of 2010, many health plans are required to fully cover several types of screenings, including those for colorectal, lung, and breast cancers, with no cost-sharing for patients. However, prostate cancer is not covered by these mandates.

Efforts to eliminate or reduce cost sharing

Recognizing the impact of cost barriers, lawmakers at the local, state and federal levels introduced new legislation in 2023 to require health plans to fully cover prostate cancer screenings. New York was the first state to eliminate member charges for screenings in 2019. Maryland and Rhode Island have also enacted similar laws. In 2022, Illinois Governor J.B. Pritzker signed House Bill 5318. This law requires health insurance and managed care plans to cover prostate cancer screenings without any cost-sharing requirements effective Jan.1, 2024.

Also noteworthy was the signing of the Veterans Prostate Cancer Treatment and Research Act of 2022. While Tricare, the health plan for uniformed military members and their families, already covered prostate cancer screenings, this law mandates creation of clinical pathways, updated annually, to guide best practices and ensure that veterans across the country have equal access to screening, treatment and survivorship services.

Other bills haven’t been as successful. At the beginning of 2022, two separate bipartisan New Jersey bills Bill S791 and NJA2795 were introduced. Both eliminate member cost-sharing for prostate cancer, however they were referred to committees and have had no further reported action. The same is true for House Bill 2842, introduced to the Pennsylvania General Assembly in 2022.

A mixed bag in 2023

In 2023, California and Washington D.C. have taken up legislative initiatives, as has the U.S. House and Senate. Following is a summary of changes in 2023:

• Prostate-Specific Antigen Screening for High-risk Insured Men Act (H.R. 1826 and S. 2821) – Also called the “PSA Screening for HIM” Act, the bill was introduced to the U.S. House of Representatives in March of 2023 and in the U.S. Senate in September 2023.This legislation would require private health insurance plans to cover preventive cancer screenings without cost sharing for men who are at high risk of developing prostate cancer – Black men and those men ages 55-69 with a family history of the disease.
• District of Columbia Law 25-63 – On Oct. 6, 2023, Law 25-63 was codified. It requires that “Each individual and group health benefits plan issued or renewed in the District of Columbia shall provide coverage for prostate cancer screening in accordance with the latest screening guidelines issued by the American Cancer Society for the ages, family histories, and frequencies referenced in such guidelines.”
• California Assembly Bill 632 – On Oct. 7, 2023, Governor Gavin Newsom vetoed Assembly Bill 632, which would have required “coverage when medically necessary and consistent with nationally recognized, evidence-based clinical guidelines” citing concerns that “…this bill exceeds the cost sharing provisions of the Affordable Care Act (ACA).”

As Sen. Cory Booker (D-N.J.) stated in his press release on the PSA Screening for HIM Act “Costs shouldn’t impose a barrier between people and lifesaving health screening services…This bipartisan legislation would make prostate cancer screenings more accessible to all high-risk men, so we can reduce health disparities and increase early detection to save lives.”

Coverage change has been slow, but hopefully state efforts and the PSA Screening for HIM Act will help reduce the disparities and monetary barriers in obtaining prostate cancer screening when needed.