The Affordable Care Act's preventive care mandate represented a landmark policy experiment. By eliminating cost-sharing for dozens of recommended services—from cancer screenings to vaccinations—policymakers removed what seemed like the most obvious barrier to preventive care: money.

The logic appeared straightforward. If people skip mammograms or colonoscopies because of $50 copays, make them free. Problem solved. Yet a decade of evidence reveals a more complicated picture. Utilization of many preventive services barely budged, even when the price tag dropped to zero.

This gap between policy intention and population behavior offers a masterclass in implementation challenges. Understanding why "free" hasn't been "enough" reveals the complex architecture of healthcare access—and points toward more comprehensive strategies for actually getting preventive care to the people who need it.

When researchers examined utilization patterns before and after the ACA's preventive care mandate, they found something surprising: the needle moved less than expected. Studies tracking mammography, colonoscopy, and routine check-ups showed modest increases at best, often in the range of 1-3 percentage points.

Some services saw virtually no change. A comprehensive review of cancer screening rates found that eliminating copays produced statistically significant but clinically modest improvements. The people who weren't getting screened before the mandate largely remained unscreened afterward.

The pattern held across different populations. Even among groups with historically low utilization rates, where you'd expect the greatest sensitivity to cost, free preventive care didn't trigger the dramatic uptake that policymakers anticipated.

This doesn't mean the mandate failed entirely. For some services and some populations, removing cost barriers did matter. But the overall picture suggests that out-of-pocket costs were only one piece of a much larger puzzle. The mandate succeeded at what it targeted—financial barriers—while revealing how much the non-financial barriers dominated.

Takeaway

Eliminating an obvious barrier often reveals the hidden barriers that were there all along, doing most of the work.

Time operates as healthcare's invisible currency. Taking a half-day off work for a screening colonoscopy costs nothing at the point of service but might cost someone their job—or at minimum, a day's wages. For hourly workers without paid leave, "free" preventive care still carries a substantial price.

Information barriers prove equally stubborn. Many people don't know which preventive services they're due for, don't understand why they matter, or haven't received recommendations from providers. The mandate made services available; it didn't make people aware of them or convince them to prioritize them.

Structural barriers compound these challenges. Limited clinic hours that conflict with work schedules. Transportation difficulties in rural areas or underserved urban neighborhoods. Childcare needs that make appointments impossible. Language barriers that turn scheduling into an ordeal.

Then there's the healthcare system itself. Primary care shortages mean months-long waits for appointments. Fragmented care means no one is tracking which screenings you've had or need. The mandate guaranteed coverage, but it couldn't guarantee a functioning system to deliver that care.

Takeaway

Access isn't a single door you unlock—it's a series of gates, and most people stop at the first one that's closed.

The most effective policy approaches attack multiple barriers simultaneously. Community health worker programs address information gaps while also helping navigate scheduling, transportation, and language barriers. Mobile health units bring services directly to underserved communities, eliminating geographic obstacles.

Paid leave policies represent an underappreciated intervention. When workers can take time off without losing wages, utilization of time-intensive preventive services increases. The policy lever isn't in the healthcare system at all—it's in labor law.

Health system redesign offers another pathway. Same-day screening availability, evening and weekend hours, and reminder systems that actually reach patients can meaningfully improve uptake. These operational changes often matter more than coverage expansion.

Perhaps most importantly, effective strategies target specific populations and specific barriers. One-size-fits-all mandates rarely work because the barriers differ dramatically across communities. Rural populations need transportation solutions. Working parents need flexible scheduling. Immigrant communities need culturally competent outreach. Policy effectiveness depends on matching interventions to actual obstacles.

Takeaway

The most powerful health policies often look nothing like health policies—they look like transportation, labor, and community infrastructure.

The ACA's preventive care mandate taught us something valuable: financial barriers are real but rarely sufficient explanations for underutilization. Solving one problem reveals the next problem in line.

This isn't an argument against cost-sharing elimination—it genuinely matters for many people. It's an argument for policy humility and comprehensive thinking. Healthcare access is a system problem requiring system solutions.

Future policy efforts should build on this lesson. Address time, information, transportation, and structural barriers alongside financial ones. Meet people where they actually are, not where the policy assumes they are. Free care that nobody uses isn't free—it's just unused.