Summary: The United States Supreme Court released a highly anticipated and critical ruling on Friday, June 27, 2025 in Kennedy v. Braidwood Management, Inc. with respect to the constitutionality of an integral component of the Affordable Care Act’s (ACA) preventive care mandate. In a 6-3 ruling, the Court held that a federal task force determining which preventive care services and items must be covered at no cost under the ACA is, in fact, constitutional.
Read on for more information and the impact to employers sponsoring group health plans.
ACA Preventive Services Mandate Background
The Affordable Care Act (ACA) requires non-grandfathered health plans and issuers, including employer-sponsored group health plans, to cover a range of recommended preventive care services without participant cost-sharing. This means that these preventive care services must be covered without imposing deductibles, copayments, or coinsurance (often referred to as “first-dollar coverage”) on plan participants when the services are provided by in-network providers.
Preventive care services and items include screening tests, immunizations, behavioral counseling, and medications that can prevent the development or exacerbation of diseases and health conditions, and include the following:
- Evidence-based items or services with an “A” or “B” rating included in the current recommendations from the U.S. Preventive Services Task Force (USPSTF), including various cancer screenings, other disease screenings (including diabetes), risk-reducing medications for women at high risk of breast cancer, nicotine patches, statin medications, and physical therapy to help the elderly avoid falls.
- Vaccinations recommended by the Advisory Committee (ACIP) and endorsed by the Director of the Centers for Disease Control and Prevention (CDC), including childhood and adult vaccinations.
- Women’s health services recommended by the Health Resources and Services Administration (HRSA) and endorsed by the Secretary of Health and Human Services, including prenatal care, contraceptives, breastfeeding services/supplies, and wellness examinations.
- Preventive care and screenings recommended for infants, children, and adolescents provided for in other HRSA guidelines.
Case Background
In 2022, the plaintiffs, comprised of four individuals and two businesses who object to the ACA’s preventive care mandate, challenged the legality of the ACA preventive care mandates in violation of the Appointments Clause in Article II of the United States Constitution and the Religious Freedom Restoration Act (RFRA). In particular, the plaintiffs objected to the USPSTF’s later expansion of the ACA preventive services mandate to include PrEP, an HIV preventive medication.
On March 30, 2023, the U.S. District Court for the Northern District of Texas ruled in favor of the plaintiffs, striking down a key component of the ACA’s preventive care mandate, and ruling that the preventive care coverage requirements based on an “A” or “B” rating by the USPSTF on or after March 23, 2010, the ACA’s enactment date, violate the U.S. Constitution.[1] Specifically, the District Court held that members of the USPSTF[2] are “principal” officers of the federal government under the Appointments Clause of the Constitution. As such, they must be nominated by the president and confirmed by the Senate. In reality, they have been appointed to the USPSTF by the Secretary of the U.S. Department of Health and Human Services (HHS), in violation of the Appointments Clause, as ruled by the District Court.
The District Court also issued a nationwide injunction, prohibiting the federal government from enforcing the impacted preventive care mandates against any health plans or issuers. Of note, such nationwide injunctions are no longer permitted under the Supreme Court’s decision in Trump v. CASA, Inc., issued the same day as the Braidwood decision.
The USPSTF-recommended services and items that were added or updated to the recommendations list after March 23, 2010, were impacted by this District Court ruling (which applied to most of them)[3]. Only those USPSTF-recommended services and items from before March 23, 2010, were not impacted by the ruling and required to be covered without participant cost-sharing. Practically, this meant only two items on this list predate March 23, 2010, and both relate to Rh(D) incompatibility screening for pregnant women.
HHS, under the Biden administration, immediately appealed the District Court’s ruling to the Fifth Circuit Court of Appeals, encompassing Texas, Louisiana, and Mississippi. On May 15, 2023, the Fifth Circuit stayed (or put on hold) the District Court’s decision pending its ruling. However, the Fifth Circuit did affirm the District Court’s ruling that members of the USPSTF had not been validly appointed under the Appointments Clause since they have not been supervised and directed by the HHS Secretary, are considered principal officers, and may not be appointed by the HHS Secretary.
The federal agencies also released FAQs guidance in mid-April 2023, providing clarity to health plans in light of the District Court ruling. Click here for a previous Risk Strategies article detailing this FAQs guidance.
On June 21, 2024, the Fifth Circuit limited its ruling to the named plaintiffs, holding that there was no basis for a nationwide injunction.
In February 2025, HHS, under the Trump Administration, filed a brief in support of the ACA preventive care mandate, and the Supreme Court heard oral arguments in the matter on April 21, 2025.
During the period from May 2023 through the present, health plans and issuers were still required to continue complying with the ACA’s preventive care mandate without imposing cost-sharing requirements on non-grandfathered health plans.
Supreme Court Ruling
The Court held that the USPSTF (or “Task Force” as referred to in the decision) members are “inferior officers because their work is ‘directed and supervised’ by the HHS Secretary, a principal officer.”[4] Justice Kavanaugh, in the majority opinion, continued on to write, “The Secretary’s ability to direct and supervise the Task Force derives from two main sources: the Secretary’s authority to remove Task Force members at will; and the Secretary’s authority to review and block the Task Force’s recommendations before they can take effect.”[5] Moreover, “the Secretary retains ultimate responsibility over whether Task Force recommendations become final decisions that mandate no cost coverage by health insurers.”[6]
As such, the appointment of the USPSTF members by the HHS Secretary as “inferior” officers is, in fact, "fully consistent with the Appointments Clause in Article II of the Constitution.”[7] Therefore, the USPSTF recommendations of evidence-based items or services with an “A” or “B” rating, in accordance with the ACA preventive care mandate, are valid and must continue to be covered at no cost to plan participants.
Notably, the Braidwood case is the fourth time the Supreme Court has ruled on a matter involving a challenge to the ACA in 13 years. This case is distinct from prior ones (2012, 2015, and 2021) challenging the entire ACA law, since Braidwood challenged only the free preventive services mandate portion of the ACA.
Impact to Employer Group Health Plan Sponsors
Now that the Court issued its decision, there is nothing for employer group health plan sponsors to change in terms of “first-dollar” coverage requirements of the applicable USPSTF recommendations under the ACA preventive service mandate, which remains in place as a result. Health plans and issuers, including employer-sponsored group health plans, must continue covering the full range of recommended preventive care services under the ACA, without participant cost-sharing.
ACA preventive care services and items remain generally popular with patients overall, as many have become accustomed to receiving them with no cost for well over a decade now. Some preventive care services were fairly prevalent even before the ACA was passed.
Additionally, they serve as an effective group health plan lever for employers to help support their workforce’s overall health and wellbeing by identifying potential medical issues early. The old adage “‘an ounce of prevention is worth a pound of cure,” attributed to Benjamin Franklin, proves to be salient in this context.[8]
If the Court had ruled in the opposite direction and struck down the ACA preventive care mandate on constitutional grounds, many plans would likely still choose to continue covering the impacted USPSTF-recommended services and items without participant cost-sharing for disease-mitigation, chronic-disease management, health-outcome disparity mitigation, and other public health purposes. Although, plans would not be required to cover them without cost-sharing in that scenario. With this Braidwood decision, employers now do not have to face that choice.
HRSA Update for 2026 Plan Years
While on the general topic of ACA preventive care services, HRSA updated its breast cancer screening guidelines in December 2024 to include additional imaging to complete the screening process.
Starting with the 2026 plan year, most health plans and issuers, including employer-sponsored group health plans, are required to cover, without participant cost-sharing, the initial mammography plus any additional imaging (e.g., MRI, ultrasound, or mammography) or pathology evaluation required to complete the screening process for malignancies.
Currently, HRSA guidelines require health plans and issuers to cover, without participant cost-sharing, mammography screening for women at average risk for breast cancer at least biennially and as frequently as annually, beginning no earlier than age 40 and no later than age 50.
Additionally, starting with the 2026 plan year, most health plans and issuers must provide individualized patient navigation services for breast and cervical cancer screening and follow-up. These services must include person-centered assessment and planning, health care access and health system navigation, referrals to appropriate support services (e.g., language translation, transportation, and social services), and patient education.
On a final related note, click here for a Risk Strategies article detailing another recent high-profile health plan coverage-related Supreme Court decision, upholding a Tennessee state law prohibiting health care providers from administering puberty blockers and hormone treatments to transgender minors.
Risk Strategies continues to closely monitor relevant developments and will provide updates when available. In the meantime, contact your Risk Strategies account team with any questions, or contact us directly here.
[1] The USPSTF “A” recommendation to cover PrEP without cost-sharing was also struck down by the District Court on religious grounds in violation of the RFRA. However, HHS did not appeal the RFRA aspect of the District Court’s ruling.
[2] Currently, the USPSTF is composed of 16 volunteers with expertise in preventive medicine and primary care, serving staggered four-year terms and operating under HHS.
[3] This includes screenings for colorectal, lung, and cervical cancers; medications for chronic conditions, such as cardiovascular disease; screening for HPV; depression and anxiety screenings; and hepatitis B and C virus screenings.
[4] Kennedy v. Braidwood Management, Inc., 606 U. S. ____ (2025) at 10.
[5] Id.
[6] Id at 14.
[7] Id at 43.
[8] See https://www.commonwealthfund.org/blog/2023/millions-could-lose-access-free-preventive-care-services and https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf
