Explainer: Preventive care coverage ruling from Supreme Court

Originally published June 1, 2023. Updated multiple times before June 27, 2025 to reflect the Supreme Court ruling.

The best things in life are free. Or so the saying goes.

And for the last 15 years, some of the best things for your health have been free too – like screenings to look for early signs of cancer, diabetes, depression or other problems, and tools to help people stop smoking, reduce their risk of heart disease or prevent serious infections.

You might not have noticed it, but you haven’t had to pay out of your own pocket for many of these for more than a decade because of a provision in the Affordable Care Act.

And the number of preventive services that you can get without spending money has grown over that time. That’s because new research can show what works best for finding or preventing future problems in people of certain ages, or with certain conditions.

A new Supreme Court ruling will shape the future of this free-to-you coverage. It preserves the role of a panel of experts called the U.S. Preventive Services Task Force in recommending which services should be covered. But it also says that the secretary of Health and Human Services can replace members of the panel. 

The current secretary recently replaced all the members of another expert panel that makes recommendations about vaccines. Those recommendations also lead to no-cost coverage of vaccines under the same Affordable Care Act provision. 

Changes to the recommendations by either panel could lead to cost-sharing for preventive care. 

Two of the top national experts on this topic are University of Michigan professors who study the clinical, equity, financial and legal impacts of American health care. One – a physician – helped design, implement and evaluate the no-cost preventive services provision. The other – a lawyer – is an expert in the legal issues surrounding this case that could potentially effect over 150 million Americans.

"The Supreme Court's decision to preserve the extremely popular ACA requirement that insurance plans cover preventive services receiving an A or B rating by the United States Preventive Services Task Force at no cost (i.e., copays, coinsurance or deductibles) to patients is a win for patients, clinicians and the strained U.S. delivery system,” said A. Mark Fendrick, M.D., a professor of internal medicine at the U-M Medical School and director of Center for Value-Based Insurance Design. "The provision enhances coverage for over 200 million insured Americans, about 60% of whom use at least one of the covered services each year, leading to better patient outcomes and in some instances lower medical costs.

However, he adds, "Clinicians rely heavily on the recommendations provided by the carefully vetted USPSTF. In a new environment where the USPSTF members are selected by the secretary, clinicians may need to turn to other sources to find unbiased scientific information needed to advise patients. Such a change will add further complexity to the already overburdened workforce and possible confusion for patients."

Fendrick also holds a joint faculty position at the U-M School of Public Health.

U-M Law School professor Nicholas Bagley, J.D., reacted to the ruling on social media with a lengthy thread. He concluded, "The big takeaway here is that the task force's recommendations are binding, just as the ACA's drafters intended. But the scheme is constitutional only because HHS Sec. Kennedy can exercise near-complete control over Task Force recommendations. A mixed bag!"
 

The case in question

The court case in question, called Kennedy vs Braidwood (formerly Braidwood vs Becerra), focuses on the part of the Affordable Care Act that requires most private health insurance companies and plans that people buy through national or state marketplaces to cover the full cost of certain preventive health care services.

This means patients pay nothing for the screenings, tests and types of prevention-oriented health counseling that have earned top recommendations for specific groups of people.

The requirement started in 2010 with a list of a few dozen items, which will still be covered no matter what the ultimate court ruling is. The list has grown to more than 90 items over the last 15 years, as new research showed which preventive care gives the most benefit for people of certain ages or with certain health risks. 

Items added since 2010, and changes to the original items, could have been potentially affected by the court case.

Fendrick and his team compiled a quick-reference list with details about how the court case might apply to each one, and published an article in Health Affairs Forefront about it. 

The team has also compiled a full policy brief on the subject and made a page on their website about the case.

Three examples:

• Back in 2010, screening tests to look for early signs of colon cancer were free for people aged 50 to 75. Two years ago, that expanded to people age 45 to 49. If the original Braidwood ruling had been upheld, insurance companies could stop making such screening free for the over 20 million Americans between 45-49 years of age.
• Back in 2010, free screening for hepatitis C virus wasn’t on the list. But as ongoing research showed the power of new medications that can clear that infection and prevent liver failure, in 2020 all adults up to age 79 became eligible for a free screening test to see if the virus is lurking silently in their bodies.  If the original Braidwood ruling had been allowed to stand, no-cost HCV screening would not be required.
• In 2024, mammograms for women over 40 got an approval that led them becoming free every other year – just like mammograms for women over 50 have been since 2010, based on a 2009 recommendation. As a result, the 22 million women between the ages of 40-50 could have had to pay out of pocket for their breast cancer screening if the Supreme Court had agreed with the plaintiffs.
   

Why did this case happen?
 

The case made its way to the Supreme Court from Texas, where a group of health providers filed suit to oppose a 2019 requirement that patients – most of them gay or bisexual men – receive free access to medications that can prevent them from getting infected with HIV, the virus that causes AIDS. 

The medication regimen, called pre-exposure prophylaxis or PrEP for short, has been available for more than a decade but receives USPSTF recommendation for high-risk individuals in 2019. Recently, U-M researcherss showed that use of PrEP by young adults rose eightfold since 2016.

Even though these providers don’t offer HIV-related care themselves, they filed to block anyone from getting it for free. They based their case on a legal argument about the way that some of the experts who recommend preventive services are appointed to their posts. Bagley explained it in this short video. The case then moved up through the federal court system until the Supreme Court heard arguments in April 2025.

If the plaintiffs had prevailed in the Supreme Court, that could have frozen the entire list of free services as if it were 2010 again. Only those patients who were eligible for a free service 13 years ago would be able to get it, and no new people could be added based on new research.

The case boils down to a legal argument about the three ways that preventive services can become free under the Affordable Care Act.

One is to earn a rating of A or B for specific types of people from the USPSTF, which evaluates research and only gives its top recommendations when the evidence of benefit is strong.  In addition to endorsing new services, the Task Force regularly updates its recommendations based on the most up to date research, as was the case for the colorectal cancer screening and hepatitis C virus examples.

In 2023, Bagley said: “The Texas judge specifically ruled that because the members of the USPSTF are not appointed in the right way, they can't make constitutional decisions, and thus their A and B recommendations that employers and insurers are supposed to follow in providing zero-dollar coverage for preventive care are unconstitutional and invalid.”

“The judge ruled that it doesn't just apply to the plaintiffs who filed the lawsuit opposing just one recommendation for prevention of HIV transmission, but it applies to everybody and to all USPSTF recommendations,” he added at the time. “And that, of course, set off an effort by the federal government to pause his decision, while appeals could work their way to the U.S. Supreme Court.”

But in a June 2024 court ruling by the Fifth Circuit Court of Appeals, Bagley posted on X (formerly Twitter), "The Fifth Circuit sided with the challengers when it came to PSTF. Its members supposedly have the authority to bind private parties, but those members weren't properly appointed. So PSTF's decisions aren't really official at all; they're just, like, its opinions.  There's a bit of a silver lining, however...for now, the PSTF-related injunction applies only to these plaintiffs, not across the whole country."

Bagley wrote a piece about the legal arguments over the appointment of USPSTF members earlier this year.

Other preventive care coverage methods

In additio to the USPSTF, the other two ways a service can become free are to get approved by a federal agency called HRSA for services specific to women or children, or in the case of vaccines to get recommended by a panel of advisors to the federal government called ACIP.

Recently, the current secretary of HHS dismissed the members of ACIP who had been appointed through a lengthy vetting process, and replaced them with others. 

The potential fixes

Even as this case worked its way to the Supreme Court, some states such as Michigan have said that they will still require cost-free coverage of these services for insurance programs that they have power over. But that doesn’t include many insurance plans run by companies and paid directly by employers.

Large insurance companies have also said that they will continue to honor the free-to-you coverage for services that previously earned USPSTF A or B ratings, while the case moves through the courts. 

A large health insurer trade organization also recently reiterated its members' commitment to coverage of vaccines after the replacement of ACIP memebers.

According to a recent consumer survey, 37% of adults said they “definitely” or “probably” expect to delay or avoid heath care due to potential costs following the ruling, and at least 2 in 5 adults said that they are not willing to pay for preventive services that are currently fully covered by the ACA.

Now that there's a ruling, and coverage of preventive care recommended by USPSTF is secure for now, Fendrick sees a chance for the attention to preventive care to have a bonus effect. 

"Given that many insured Americans who are eligible for no-cost preventive care have not received these potentially lifesaving services, the court's decision offers a 'second chance' for key constituents, including those who initiate screening and diagnose and treat these conditions, to better educate eligible individuals about no-cost screening and to help them navigate the screening continuum."