RFK Jr. Puts Health Insurers in Limbo by Dropping Covid-19 Shot

US Health Secretary Robert F. Kennedy Jr.’s decision to pull the Covid-19 vaccine from the CDC’s recommended immunization list for healthy children and pregnant women means health plans must navigate whether to keep providing coverage for the shot.

Kennedy announced Tuesday he was removing the Covid-19 vaccine from the Centers for Disease Control and Prevention’s recommended immunization schedule, a list that’s tied to what various private insurers and Medicaid expansion programs are required to cover with no cost-sharing.

The change will likely curtail access to the Covid-19 vaccine for children and pregnant women if health plans drop coverage or increase cost-sharing after no longer being required to pay for the shots. That move would not only leave patients to start paying out of pocket for the vaccines, but place insurers in a tough spot with beneficiaries who are vulnerable to the virus or seeking to prevent it.

“Insurance companies are going to raise the claim they don’t have to cover it,” said James Hodge, a health law professor at Arizona State University. “That’s problematic because there’s a lot of people that may have been relying on it to avoid Covid.”

Kennedy’s announcement in a video posted on X appeared to skip recommendations from the Advisory Committee on Immunization Practices, a panel of outside medical experts who guide the CDC on vaccine policy and vote for any new or updated recommendations to the schedule.

The ACIP holds weight because the Affordable Care Act and the Inflation Reduction Act tie coverage in the commercial and Medicaid markets to the committee’s recommendations, attorneys say. That committee also votes on whether vaccines should be added to the federal Vaccines for Children program, which provides vaccines to children who can’t to afford them.

The panel is currently scheduled to meet starting June 26 to consider Covid-19 vaccines.

The HHS did not respond to request for comment on further details of the announcement.

‘Gray Area’

Insurance companies are still trying to figure out where they stand with Kennedy’s decision. As of Wednesday, the CDC website still recommends that everyone ages 6 months and older should get the Covid-19 vaccine.

The Blue Cross Blue Shield Association, which represents insurers that provide coverage to more than 115 million people across the US, said it’s “carefully reviewing the FDA’s guidance on COVID-19 vaccinations to ensure patients are receiving safe and effective care.”

“Prevention is essential to individual health,” a company spokesperson said in a statement. “All BCBS plans provide access to preventive services, including COVID-19 vaccines, to promote better health and continued well-being for every American we cover.”

AHIP, the national trade association representing the health insurance industry, also said it was still reviewing Kennedy’s announcement.

A new “gray area” has been created for health plans as they navigate Kennedy’s announcement, said Richard Hughes IV, a member of Epstein Becker & Green PC and a former executive with Covid-19 vaccine manufacturer Moderna Inc.

Some insurers could continue to provide coverage without cost-sharing, or drop it. Additionally, while the Affordable Care Act requires insurers to cover vaccines recommended by the ACIP, it makes no reference to the CDC’s vaccine schedule.

“Is there a difference, or could there be a difference, between official departmental policy and what payers are required to cover?” Hughes said.

Lisa Campbell, a principal at Groom Law Group, said health plans will likely wait to see whether ACIP adopts Kennedy’s changes at its June meeting before altering coverage. But if a plan wanted to alter coverage beforehand, the legal argument gets a little “murky.”

“What authority does the HHS secretary have to circumvent the process and basically make this recommendation and approval outside of that committee process?” she said, adding that’s not addressed in the Affordable Care Act.

Hughes said he thinks the panel’s recommendations can stand independent of the official vaccine schedule, but if insurers decide to alter coverage and increase cost-sharing, fewer people will seek out shots.

“We know that any amount of out-of-pocket means that patients tend to be more likely to walk away,” he said.

Insurers are unlikely to drop coverage for children and pregnant women unless it becomes a “political hot potato,” said Roberta Casper Watson, a benefits attorney at the Wagner Law Group. But she agreed health plans could start imposing cost-sharing if they’re allowed.

“We’ll have to see what the administration does with it,” Watson said.

Various Plans

The announcement is also unclear on how this decision will affect federal and subsidized health plans that operate differently, legal experts say.

For example, no details were provided on if this will change or rescind coverage for the Vaccines for Children’s program.

“VCP is a critical pathway to assuring access to vaccines for children often most in need, but if Covid-19 is not among ACIP’s recommended immunizations for kids, it will most likely not be distributed through state and local governments and other providers for kids most in need,” Hodge said.

People covered by Medicaid and the Children’s Health Insurance Program are likely to be affected most by this action because it targets pregnant women and children, said Ana Santos Rutschman, a law professor at Villanova University. Those plans are administered jointly by the federal government and individual state governments.

A “patchwork of other programs,” including Medicare and private insurance, could react differently to the decision, Rutschman said.

“All of those programs have different legal structures and vaccines get by differently,” she said. “They’re not going to just say, ‘Oh, we’ll cover it.’ Some might, but the end game is here to remove it from the things they have to cover. There will be some coverage for vaccines, but this is beginning to chip away at it.”