U.S. Preventive Services Task Force (USPSTF) Grade Definitions and Examples of Services in Each Category.

In early 2009, the drafters of the Affordable Care Act (ACA) agreed that as part of their insurance coverage Americans should have access to clinical preventive services without cost sharing. To avert demands for services of unclear effectiveness, they proposed that health plans should, at minimum, cover services with an A or B grade (see table) from the U.S. Preventive Services Task Force (USPSTF), a federally sponsored expert panel known for making careful assessments grounded in rigorous scientific analysis. For advocates of evidence-based medicine, this provision represented a singular achievement.

But the USPSTF’s transition from arbiter of evidence to full-fledged policy authority has provoked sharp debate. Although many people, including current USPSTF leaders, have publicly lauded the new authority, others believe it threatens the task force’s mission and future. When challenged over past determinations, the USPSTF asserted that it focused on the science, leaving policy decisions to others — a claim now difficult to sustain.

Hanging over the USPSTF are questions about whether, in the face of lobbying pressures and enhanced policy responsibilities, it can maintain its historical commitment to basing its analyses on evidence alone. As former USPSTF chair Bruce Calonge noted, the new policy authority is a double-edged sword: it ensures that the task force’s work will have an effect but also “puts a pressure on your decision-making” and raises the economic stakes in a manner that is “not positive.” Having reviewed archival documents and conducted more than 30 interviews with current and former USPSTF leaders, members, liaisons, and staff members, as well as ACA architects and others, we believe that assessment warrants close attention.

The USPSTF was established in 1984, at a time when health care purchasers were reluctant to reimburse clinicians for preventive care. To overcome this resistance, U.S. Deputy Assistant Secretary for Health J. Michael McGinnis convened a panel of experts in primary care and public health to analyze the literature and build an “airtight case” for effective preventive services. Though supported by the Office of Disease Prevention and Health Promotion, the USPSTF was configured as a nonfederal body to insulate it from political and commercial pressures. Its findings were framed as advice to clinicians, not the government, and it was encouraged not to consider costs.1

The USPSTF developed a reputation for a commitment to data and a willingness to issue guidance that challenged conventional thinking. Former USPSTF staff editor Steven Woolf recalled that “speaking truth to power” was central to its mission. Widely used screening tests that were weakly grounded in evidence were seen as “red meat” for task-force intervention. Unlike professional societies’ guideline-development processes, which typically relied on expert opinion, the USPSTF followed a predetermined, data-driven method that weighed the magnitude of benefits and harms as established by high-quality research and compelled it to withhold support when strong evidence was lacking.2

The task force was thus at the vanguard of a movement to render clinical practice more evidence-based. It popularized some practices that propelled this upheaval, including pairing its reviews with grades ranging from A (strongly recommended) to D (not recommended). The group’s iconoclastic spirit and quasi-governmental status placed it on the far outskirts of Washington political culture.

Yet its reputation for rigor attracted attention from advocates of evidence-based policy. In 2000, an Institute of Medicine (IOM) committee noted that some experts thought Congress should delegate Medicare preventive-services coverage decisions to the USPSTF. But the committee, led by a former task force chair, warned that such a step could jeopardize the USPSTF’s credibility, noting that it was “not intended or constituted to consider the cost and other implications of its recommendations for the Medicare program.”3 Instead, the IOM proposed linking USPSTF findings and coverage policy: the task force could assess the science and Medicare’s coverage advisory committee could sort out the insurance particulars.

Prevention advocates took up the IOM’s call. In 2008, the Medicare Improvement for Patients and Providers Act gave the secretary of health and human services the discretion to add preventive services to Medicare coverage if the USPSTF gave them an A or B rating. The task force wasn’t consulted in advance about the legislation, but its leaders and federal overseers were generally thrilled with the added influence. With the secretary acting as a filter for coverage determinations, the task force could focus on the science while knowing it was helping to remove barriers to evidence-based services.

The next year, however, as the ACA was being drafted, leading members of the USPSTF were shocked to hear that their findings might automatically set a floor for preventive-services coverage, now with no filter. They worried about the task force’s ability to maintain its stringent evidence standards in the face of this new authority.

Political risks surfaced even before the ACA passed, when USPSTF recommendations on breast-cancer screening, which gave a C rating to mammography for women in their 40s, ignited a firestorm in Congress during the health care reform debate. One month later, the Senate amended the ACA to guarantee mammography coverage, effectively overruling the task force’s assessment of the science.

With the ACA’s passage in March 2010, critics began questioning whether the USPSTF was equipped to perform the work that the law required. In 2011, a former Centers for Medicare and Medicaid Services official argued that the ACA had made the USPSTF into a “de facto regulatory agency” — but one lacking the “requisite expertise, capacities, or regulatory traditions” for evaluating the cost ramifications of its conclusions or incorporating stakeholders’ views. Opposition to the group’s new role emerged even among longtime proponents of evidence-based medicine. In 2013, Steven Woolf, along with Doug Campos-Outcalt, then the American Academy of Family Physicians liaison to the task force, argued that Congress should sever the link between coverage policy and the USPSTF. “Coverage decisions, like other aspects of public policy, should not always be dictated solely by science,” they asserted.4 The ACA had burdened the USPSTF with a level of policy authority that was liable to alter its determinations by engendering “a subliminal pressure to reinterpret the evidence, knowing the ramifications, and to lower the threshold for A and B recommendations.”

The USPSTF now finds itself required to make complex decisions that appear to demand inputs beyond evidence. “The very thing that the task force wanted to get away from, which is to get involved in the whole cost discussion . . . it’s now right in the middle of it,” observed one former member. Critics of the arrangement maintain that it’s bad for policy, because the USPSTF possesses neither the expertise nor the tradition of incorporating cost or other extrascientific factors into its determinations but now must make decisions with broad systemic consequences.5 Former USPSTF members with experience in benefits design aver that determinations about what the evidence says are different from coverage decisions. Critics also see the linkage as bad for the task force because its methods no longer appear to match its policy responsibilities, raising inevitable questions about how it reaches its conclusions. “I do think personally that it’s impossible . . . to not in the back of your mind say, ‘Oh my God, I am taking something away from people. I am going to make this a B so that it becomes a part of this insurance package,’” argued one former USPSTF vice chair.

The task force’s new role has brought with it new scrutiny. The American Cancer Society suggested that the USPSTF be stripped of its “inappropriate” policy duties. The National Business Group on Health, which represents many large U.S. employers, expressed serious concern about some task force analyses and has called for the creation of a separate coverage-policy committee. “They know nothing about coverage. They frankly know nothing about benefit design. Those are things that they should have never been given,” asserted Helen Darling, former chief executive of the business organization.

USPSTF leaders acknowledge that crafting recommendation language that’s explicit about insurance coverage presents a new challenge. Privately, they concede that having a separate entity tasked with determining coverage policy might be beneficial. The ACA’s endorsement of the importance of evidence has thus opened the door to a serious political challenge to an institution founded on the principle that the science of evidence-based analysis should be kept at arm’s length from the politics that for too long informed — and even governed — the business and practice of medicine. What does it mean to “speak truth to power” once you have been given real power?