Angus Chen , 2025-04-17 08:30:00
For a decade and a half, Americans have been guaranteed that no matter their health insurer, certain preventive care like cancer screenings are free of charge. That’s because an Affordable Care Act provision has required insurers to fully cover services given an A or B recommendation by an expert task force.
That may soon change. On Monday, the U.S. Supreme Court will hear a challenge to this statute in the case of Kennedy v. Braidwood Management. Either way the court decides, legal and medical experts told STAT, the ruling could have profound ramifications for the future of preventive health care in the United States.
Striking down this ACA provision means insurers can deny coverage for many of the services the United States Preventive Services Task Force, a volunteer panel of experts, recommended after the ACA’s passage. Those services include statins, HIV prevention drugs called PrEP, breast cancer prevention medications, lung cancer screening, and colorectal cancer screening at the age of 45 to 49.
The possibility of that outcome has health experts worried. “The fear is that this will be a big step backwards in reducing the burden of cancer,” said Scott Ramsey, a cancer researcher, physician, and health economist at the Fred Hutchinson Cancer Center. If some insurers decide to tack on cost-sharing to cancer screenings, that could lead to fewer people deciding to get screened. “Even $20 copays can reduce adherence substantially” to cancer screenings, Ramsey said, which could ultimately lead to more cancers being diagnosed at advanced stages.
Loss of mandated PrEP coverage would also be a setback in the HIV/AIDS epidemic, said Bennett Klein, senior director of litigation and HIV law at GLAD Law. “It would be unfathomable to the hundreds of thousands of people who died in the first three decades of the HIV epidemic that there would be a safe daily pill that would prevent HIV transmission close to 100%,” Klein said. “The challenge is that too few people who need PrEP actually have access to it. We need to remove barriers, rather than reimpose barriers.”
Aside from the cost of the pill itself, insurers are also currently required to cover related testing that can cost thousands of dollars per patient as part of the task force recommendations. In an amicus brief that GLAD Law and Lambda Legal filed to the Supreme Court, Klein said they estimated that removing cost-sharing prohibition from PrEP coverage could lead to 20,000 new HIV infections over the next five years, a calculation based on work from a group of Yale epidemiologists.
The lawsuit was originally filed in 2022 by Braidwood Management, which represents a group of conservative Christian employers in Texas. At the time, they argued that the requirement to cover PrEP was a violation of their freedom of religion and that the mandate for private insurers to cover USPSTF recommendations more broadly was unconstitutional. They argued that because task force members aren’t appointed by the president and confirmed by Congress, it’s unconstitutional for this body to have the authority to dictate what health insurers must cover. Instead, they argued only “principal officers” who go through that process, like the secretary of Health and Human Services, and those under these officers’ command, should have that power.
In 2023, the U.S. District Court for the Northern District of Texas agreed with the plaintiffs’ arguments. When the Biden administration appealed, the 5th Circuit Court of Appeals affirmed that ruling, though it ruled that only the plaintiffs were allowed to exclude covering task force recommended services for their employees. The Biden administration then took the case to the Supreme Court, which is only looking at whether binding no-cost coverage to task force recommendations is constitutional.
The Trump administration and HHS Secretary Robert F. Kennedy Jr. are now continuing the case. In the Trump administration’s filing, it argues that the ACA provision is constitutional because it believes the task force is under the authority of the HHS secretary. The government argued the HHS secretary can appoint and remove task force members at will and can also create regulations requiring secretarial approval before task force recommendations become binding on health insurers.
The current government’s decision to pursue the case has made somewhat strange bedfellows of the Trump administration and various advocacy groups, including LGBTQ+ organizations, and its decision to defend Obamacare has surprised many. The case is “one of the latest in a series of litigation attacks brought against various provisions of the Affordable Care Act,” said Wendy Parmet, a constitutional law scholar at Northeastern University. “It’s surprising because Trump is not a fan of the Affordable Care Act and vowed to replace the Affordable Care Act in his first term.”
But experts noted that should the Supreme Court side with the Trump administration, it would provide a basis for empowering the administration to veto certain task force recommendations. For instance, in this case, if the HHS secretary decides that insurers shouldn’t have to cover PrEP or diabetes screenings or colonoscopies, then they don’t have to — regardless of what the task force recommends.
“This is about giving them the power, to some extent. This is a fight to say, the secretary has the power. If they win, they can uphold the experts’ recommendations or attempt to veto them, which then would likely trigger a court challenge,” said Andrew Pincus, a lawyer representing the American Public Health Association in an amicus brief filed to the Court.
Regardless of the outcome, if insurers are no longer required to cover certain task force recommended services, it’s an open question of whether they actually would stop providing cost-free coverage of those services. Preventive medicine can be incredibly cost-effective, after all, as typically preventing a disease like advanced cancer tends to be a lot cheaper than treating it.
“Most cancer screening we do is cost-effective. What you get for improving quality and quantity of life for what you spend, it’s one of the best deals you can make,” said Fred Hutch’s Ramsey. “That doesn’t mean it’s cost saving. It’s unlikely that cancer screening saves insurance companies money.”
One issue is that the U.S. health care system is a patchwork of different providers, and as people move to different jobs, states, or get older, their insurance provider often changes as well. People’s health insurers might change between their first cancer screenings and when they actually get cancer. Most of the savings coming from cancer prevention is actually going to Medicare, Ramsey said, since it covers older adults who are most likely to get such illnesses. So, it’s possible that some insurers may decide it’s not worth it to them to keep paying fully for everyone’s cancer screenings if they don’t have to.
“For for-profit Medicare Advantage programs, they might do some hard math and decide it’s better to have a copay,” Ramsey said.
Economic cost doesn’t play a role in the task force’s recommendations, Ramsey said. Although, he added, the task force does have “a very high bar for an A or B rating,” he said. “You have to have randomized controlled trials and lots of evidence showing clinical benefit that exceeds harm.” That gives some confidence to people that these recommended services are good for the health of the nation.
And major tests for breast, colorectal, cervical, and lung cancer screening have indeed saved lives, Ramsey said. “Tens of thousands of lives, there’s no question. We would have a much worse picture of deaths due to those cancers without widespread screening,” he said.
Should those screenings become harder to access for a reason like added costs, it is likely the future would see less of those benefits in lives saved and treatments averted.