Judge blocks feds from enforcing ACA's preventive care coverage mandates

A federal judge on Thursday issued a ruling that would block the federal government from enforcing mandates for preventive care within the Affordable Care Act, which required insurers to provide a slew of critical screenings to members at no cost.

Judge Reed O'Connor of Texas' Northern District Court ruled last fall that multiple recommendations from the U.S. Preventive Services Task Force ran afoul of the Constitution's Appointments Clause. The lawsuit was led by two Texas residents who argued that ACA requirements to cover birth control and preexposure prophylaxis (PrEP) drugs, which prevent HIV, at no cost violated their religious beliefs.

While the initial suit focused on PrEP and birth control, both of which are politically controversial with conservatives, Thursday's ruling does extend to preventive screenings for certain cancers, like lung cancer, as well as behavioral health conditions, such as anxiety, experts at the Kaiser Family Foundation said on a briefing Thursday afternoon.

It would not apply to preventive care recommendations issued before the ACA was put in place in March 2020, according to the briefing. Certain diabetes, heart health and women's health screenings could also be impacted.

Larry Levitt, executive vice president for health policy at Kaiser Family Foundation, said that consumers could be shielded, at least in part, from the ruling initially, as commercial payer contracts are already in place.

Payers aren't likely to drop coverage of the impacted services altogether, he said, but would likely dial up member cost-sharing down the line.

"I think, particularly for PrEP, there could be substantial cost-sharing for enrollees," he said.

The lawsuit is likely to be appealed and seems headed for another showdown before the Supreme Court over the landmark 2010 healthcare law. O'Connor is also the federal judge who initially ruled that the entire ACA was invalidated once Congress zeroed out its individual mandate penalty, as the mandate was considered one of the key "legs of the stool" within the law.

Preventive care elements of the ACA not effected by O'Connor's ruling include immunizations, preventive care and screenings for infants, children and adolescents and preventive care and screenings for women's health, according to Andrew Pincus, visiting lecturer in law at Yale Law School and a Supreme Court and appellate lawyer.

Those services also could be at risk of losing coverage, he said during a webinar on the ruling.

“It seems likely that the plaintiffs in this case will not be happy with those decisions and will appeal those decisions to the Fifth Circuit and seek to expand the invalidation of preventative services beyond what Judge O'Connor has done,” he said during the webinar.

That case also made it to the Supreme Court, which deemed the mandate itself unconstitutional but determined that it could be excised from the rest of the ACA, which covers a slew of health priorities beyond coverage from fraud to value-based care.

Critics of the preventive care lawsuit have expressed concern that it could lead to patients avoiding critical preventive care. A recent survey from Morning Consult found that more than half would be unwilling to pay for preventive care if it was no longer covered by their insurance.

“The resulting impacts of this decision will be widespread, starting with the fact that it creates uncertainty for people seeking care. Our extensive listening work has shown us that people look for certainty that they can afford and depend on much-needed preventive health care services," Natalie Davis, CEO of United States of Care, said in a statement. "Throwing a wrench into that certainty and requiring additional out-of-pocket costs will deter people from seeking care."

The American Medical Association (AMA) said in a statement that it is "alarmed" by the ruling and the implications it has for preventive services. Doctors "know the inevitable result when courts interfere with insurance coverage of effective, proven interventions," the AMA said.

"Providing insurance coverage for screenings and interventions that prevent disease saves lives—period. Invalidating this provision jeopardizes tools physicians use every day to improve the health of our patients," AMA said in a statement. "And the burden of losing this first-dollar coverage will fall disproportionately on low-income and historically marginalized communities that are least able to afford it and are often at high risk of developing preventable medical conditions."

Senior Editor Heather Landi contributed to this report.