The Supreme Court upheld a mandate under the Affordable Care Act (ACA) that requires private insurers to cover specific preventive services at no cost to patients—a big win for tens of millions of Americans who rely on these free services such as cancer and diabetes screenings and medications to reduce heart attacks and strokes.

In sustaining the mandate, the Court underscored the authority of the Secretary of Health and Human Services over the national expert panel that determines which of those free medical services should be guaranteed.

A study by the Stanford Prevention Policy Modeling Lab (PPML) recently found that almost 30% of privately insured individuals, or nearly 40 million people, use at least one of the free preventive health services guaranteed under the ACA. The continued guarantee of free access to those services was under threat by Kennedy v. Braidwood Management Inc., in which a ruling from a Texas district court found the ACA preventive services mandate was unconstitutional.

The vote was 6-3 with Chief Justice John Roberts, Justice Amy Coney Barrett and Brett Kavanaugh joining the court’s three liberal justice in the majority.

“This is a clear win for public health,” said Josh Salomon, PhD, a professor of health policy and director of the Stanford PPML. and senior author of the study published in JAMA Health Forum. “Our research shows that tens of millions of people rely on preventive services recommended by the USPSTF, often without even knowing it—these services are embedded in everyday care. The Supreme Court decision keeps that access in place, which is critical.”

Salomon noted, however, that the ruling also highlights potential concerns over the continued independence of the U.S. Preventive Services Task Force (USPSTF) in determining which services must be covered. The volunteer panel includes 16 nationally recognized experts in prevention, evidence-based medicine and primary care. Their recommendations are grounded in strong evidence that prevention and early detection improve health.

The opinion of the Court notes explicitly that the HHS Secretary has the power to remove Task Force members and to review and block the Task Force’s recommendations before they can take effect.

“The ruling reminds us that the future of these protections may depend more on political leadership than in the past,” Salomon said. “That’s something to watch as we think about how to sustain evidence-based care. The Court has kept the gate open on the preventive services guarantee but emphasized that the key is tucked in the pocket of the HHS Secretary.”

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The Case Before the Court

The legality of mandating USPSTF-recommended services was the focus of the Supreme Court case. The ACA requires that private insurers cover specific preventive services at no cost to patients, such as blood pressure, diabetes and cholesterol tests, and cancer, HIV and hepatitis C virus screenings. The mandate also requires that most health insurance plans must cover all FDA-approved contraceptives.

In the Braidwood case, the Supreme Court had to evaluate the claim that the mandated coverage of USPSTF-recommended services violates the Appointments Clause of the Constitution, which declares that “officers of the United States” be appointed by the president and then confirmed by the Senate. The USPSTF health experts are a volunteer panel not appointed by the president.

So while the court upheld the mandate for preventive services, Kavanaugh, writing for the majority, said the Task Force members were “inferior officers” who should be supervised and directed by the HHS secretary—who in turn reports to the president.

Who Uses Preventive Services?

The study by the Stanford PPML at the Stanford School of Medicine and Harvard T. H. Chan School of Public Health looked at claims data from privately insured individuals in the United States, state by state. They determined how many people received, at no cost, any of the 10 services most likely jeopardized by Braidwood.

They found that almost 30% of privately insured individuals, and almost half of privately insured women, use at least one of the 10 services at no cost. They found that 13 states have at least 1 million recipients of these free services—including 3 million (30%) people in Texas, where the case originated.

“Preventive services are essential health care. Eliminating guaranteed free access to these services would likely have led to lower use of evidence-based screening and treatment interventions, and worse health outcomes,” said Salomon.

The Stanford study focused on a cohort of 16.1 million employee-sponsored health insurance enrollees in the MarketScan database, representing 130.9 million enrollees nationwide. The team identified preventive services that most likely would have been impacted if the Supreme Court upheld the Texas decision. The services included statin use to prevent cardiovascular disease, pre-exposure prophylaxis for HIV, medication to reduce breast cancer risk, and new or expanded screenings for breast cancer, cervical cancer, colorectal cancer, lung cancer, hepatitis B virus infection, hepatitis C virus infection, and HIV infection. Among the 39.1 million individuals nationally who received any of these services without cost-sharing, the most widely used services were screenings for cervical cancer and hepatitis C virus and HIV infections.

“The decision in this case will be important for millions of people with private insurance, across all states, who are currently benefiting from free preventive services thanks to the ACA mandate,” said lead author of the study, Michelle Bronsard, MSc, a research fellow at the Stanford Institute for Economic Policy Research (SIEPR) and incoming PhD student at Stanford Health Policy.

The other PPML members and co-authors of the study were Adrienne Sabety, PhD, assistant professor of health policy at Stanford and a SIEPR faculty fellow; Minttu Rönn, PhD, a research scientist at the Harvard T.H. Chan School of Public Health; and Nicole Anne Swartwood, MSc, a research analyst at the Harvard T.H. School of Public Health.