Supreme Court Upholds Preventive Care Provision in Affordable Care Act

The case stemmed from a lawsuit brought by conservatives seeking to block free preventive care, including medicine to prevent H.I.V. transmission.

The Supreme Court on Friday upheld a provision of the Affordable Care Act that requires insurance companies to offer some kinds of preventive care for free.

In a 6-to-3 decision, written by Justice Brett M. Kavanaugh, the majority ruled that a federal task force that determines which preventive health measures insurance companies must cover at no cost to the insured was constitutional.

The decision appears to safeguard coverage for tens of millions of Americans who receive some free health care services, including cancer and diabetes screenings, medications to reduce heart disease and strokes and eye ointment for newborns to prevent infections causing blindness.

Chief Justice John G. Roberts Jr. and Justice Amy Coney Barrett, as well as the liberal wing, Justices Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson, joined the majority opinion.

The remaining conservative justices, Clarence Thomas, Samuel A. Alito Jr. and Neil M. Gorsuch, dissented.

Mitchell Warren, the executive director of an H.I.V. prevention organization, AVAC, praised the decision, calling its outcome a relief.

“Preventive services across health care are cost-saving and lifesaving, and I am grateful that the Supreme Court found on the side of evidence, logic, public health and human rights,” he said.

The case is the latest lawsuit targeting the Affordable Care Act, President Barack Obama’s central legislative achievement. The heath care law survived three previous major challenges at the Supreme Court, in 2012, 2015 and 2021. Chief Justice John G. Roberts Jr. cast the decisive vote to save the law in 2012, a crucial milestone in which the justices upheld the law’s core mandate that most employers provide health insurance for their workers.

The dispute decided on Friday centered on the U.S. Preventive Services Task Force, a panel of experts in the Department of Health and Human Services that recommends preventive medical services, including screenings and medications to prevent serious diseases.

The task force was devised to determine preventive health services that insurance companies are required to offer for free under the Affordable Care Act.

The challenge to the task force focused on the process for selecting its members. The task force is composed of 16 volunteers, all nationally recognized experts in prevention and primary care, including family medicine, geriatrics and obstetrics.

Members are appointed by the secretary of health and human services to serve four-year terms.

At issue was whether these members are legally considered “inferior” or “principal” officers. Under the Constitution, “principal officers” must be appointed by the president and confirmed by the Senate. The Affordable Care Act said the task force members and their recommendations “shall be independent and, to the extent practicable, not subject to political pressure.” The challengers argued that this made them “principal officers.”

But in the majority opinion, Justice Kavanaugh wrote that the structure of the board makes clear that its members are subject to political control and so count as inferior officers. The secretary of health and human services can review the board’s recommendations and block them from going into effect, and can also remove the members before their terms are up.

“Task force members are supervised and directed by the secretary, who in turn answers to the president, preserving the chain of command in Article II” of the Constitution, he wrote, adding, “As a result, appointment of task force members by the secretary of H.H.S. is consistent with the appointments clause.”

In dissent, Justice Thomas noted that at the time the case was filed, the task force was appointed by a subordinate official in the department, a system that was since changed to elevate that power to the secretary. He added that the government had established a new statutory theory for why the current system is permissible on appeal.

In 2022, a group of plaintiffs, including individuals and Christian-owned businesses, sued in Texas, arguing, among other points, that the members of the task force had not been properly appointed.

The challengers in the case, Kennedy v. Braidwood Management, No. 24-316, claimed that the health care law had empowered the task force to “unilaterally” determine the preventive care that private health insurance must cover. They took particular issue with a mandate the task force issued that requires insurance companies to cover pre-exposure prophylaxis treatment, medication known as PrEP, which can prevent H.I.V. transmission.

Some of the plaintiffs claimed that they had suffered economic harm from being forced to pay higher premiums that included services they did not want to offer. Some also argued that they had suffered religious harm, claiming that the PrEP drugs would “encourage and facilitate homosexual behavior” in conflict with their religious beliefs.

They brought the litigation in an area of Texas where cases often go to a district court judge, Reed O’Connor, who frequently sides against Democratic policies. Judge O’Connor agreed with the plaintiffs’ argument that task force members had been unconstitutionally appointed.

The U.S. Court of Appeals for the Fifth Circuit then somewhat narrowed the lower court’s ruling, but concluded that the task force indeed had “unreviewable power” to issue recommendations of preventive care that insurers must cover. That independence from supervision by the health secretary, the court found, rendered task force members “principal officers” who have not been “validly appointed” under the Constitution.

In September 2024, the Biden administration asked the justices to weigh in. Government lawyers argued that the appeals court had relied on an “erroneous understanding” of the Constitution and that task force officers were “inferior officers” subordinate to the health secretary. They could be removed at will, the lawyers argued, which meant their appointment did not violate the Constitution.

Donald J. Trump took office after the justices agreed to hear the case, but the Trump administration stuck with Mr. Biden’s position, agreeing that the task force was constitutional.

Apoorva Mandavilli contributed reporting.

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