Appeals court upholds ACA’s preventive services mandate, but opens door to future challenges

Dive Brief:

  • A federal appeals court on Friday preserved the Affordable Care Act’s popular mandate that private insurance cover preventive services at no cost to patients.
  • However, the U.S. Court of Appeals for the 5th Circuit ruled that the plaintiffs, a group of Christian companies, did not have to comply with the mandate, leaving the door open for a broader ruling in the future that could undermine the mandate nationwide.
  • The appellate panel also ruled the task force that determines which preventive services are free must be confirmed by Congress and asked a lower court to review the authority of the groups that make those decisions for contraception and vaccines.

Dive Insight:

Two Christian-owned companies in Texas, Braidwood Management and Kelley Orthodontics, sued the federal government in 2020 over the ACA’s requirement that their health plans cover contraception, HPV vaccines and medicines to prevent HIV for free, arguing the services violated their religious beliefs.

The plaintiffs contended the law’s mandates were invalid because they’re issued by the U.S. Preventive Services Task Force (USPSTF), a group of expert volunteers that aren’t confirmed by the Senate and therefore lack constitutional authority to issue legally binding recommendations on preventive care.

Last year, Judge Reed O’Connor of the U.S. District Court for Northern Texas agreed with the employers, ruling that the government could not force insurers to cover services recommended by the USPSTF for free.

The judge’s decision nullifying the preventive services mandate nationwide never went into effect, as it was put on hold while the Biden administration appealed the case.

On Friday, the 5th Circuit overturned O’Connor’s ruling, finding he had overreached in banning the preventive services mandate nationwide. However, the three-judge panel agreed that the USPSTF didn’t have constitutional authority to issue recommendations.

“Our decision today is something of a mixed bag,” the court wrote.

Moving forward, members of the USPSTF must be nominated by the president and confirmed by the Senate, the 5th Circuit ruled.

The panel did not decide, however, whether the groups that recommend which vaccines and contraceptives should be free for consumers have the authority to do so. Those groups are the Advisory Committee on Immunization Practices (a committee within the Centers for Disease Control and Prevention) and HHS subagency the Health Resources and Services Administration.

Instead, the 5th Circuit sent that question back to O’Connor, who has a history of targeting the ACA: In 2018, O’Connor ruled the entire ACA was unconstitutional, though the Supreme Court upheld the law in a 7-2 decision in 2021.

The current case has been closely followed, as it threatens access to preventive services for the majority of Americans who receive health insurance through their employer: some 164 million people as of last year, according to government estimates.

Polling shows these mandates are some of the most popular provisions of the ACA passed more than a decade ago. Free preventive care staves off worse health outcomes — and higher costs — for patients down the line. Research shows even small levels of cost-sharing can cause patients to use less medical care.

As such, the 5th Circuit’s decision is a relief for U.S. citizens that get insurance through their job, according to patient advocacy and health policy groups.

“Thankfully for now, today’s ruling preserved access to life-saving preventive health care services,” said Yael Lehmann, the interim executive director of Families USA, a consumer advocacy group, in a statement.

However, it “paves the way for future lawsuits that jeopardize access,” Lehmann added.

The Harvard Law School’s Center for Health Law and Policy Innovation also said in a statement it was “very concerned” about the long-term impacts of the court’s decision.