Texas federal court rules against ACA coverage mandate for HIV prevention drug 


Boram Kim


US District Judge Reed O’Connor ruled on Wednesday that requirements to cover HIV prevention drugs under the Affordable Care Act (ACA) violated religious freedom. 


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The ruling out of Fort Worth sided with a group of conservative Christians who filed a class action lawsuit in 2020 against the federal government. The plaintiffs argued that the mandate to provide free coverage for HIV pre-exposure prophylaxis, or PrEP, violates their constitutional right to religious freedom by requiring employers and policyholders to cover the costs of medications that conflict with their faith and personal values.

O’Connor found that the Department of Health and Human Services (HHS), the defendant in the case, did not provide “compelling” evidence for its argument that private religious employers should be mandated to cover PrEP, “with no cost-sharing and no religious exemptions.” 

The US Supreme Court ruled in favor of the ACA mandate for contraception in 2 previous cases, Burwell v. Hobby Lobby and Zubik v. Burwell, where groups claimed employee coverage for contraception violated their religious freedom under the 1993 Religious Freedom Restoration Act (RFRA).

O’Connor has ruled against the ACA in a series of lawsuits that have come through his court over the years. In 2018, he ruled that the entire ACA was unconstitutional, a decision that was eventually reversed by the US Supreme Court.

Medical advocates fear the case could set precedent for blocking access to sexual and reproductive health care, also mandated under ACA, and impact services and medications, including cancer and heart disease screenings, for the more than 150 million Americans who are covered by employer-sponsored health care plans. 

“This ruling is yet one more instance of unacceptable interference in scientific, evidence-based health care practices that must remain within the sanctity of the provider-patient relationship,” Dr. Marwan Haddad, Chair of the HIV Medicine Association, said in a statement.

“Denying access to PrEP threatens the health of the more than 1.2 million Americans who could benefit from this potentially lifesaving intervention. Religious refusal laws allowing the personal beliefs of employers or health care providers to dictate access to prevention, care and treatment services are discriminatory and dangerous. These laws ultimately hurt everyone.”

Advocates warn lack of access to HIV preventive measures furthers threatens high-risk populations. According to the Kaiser Family Foundation, women of color, particularly Black women, are disproportionately affected by HIV, “accounting for the majority of new HIV infections, the greatest prevalence, and highest rates of HIV-related deaths” among HIV-infected American women. 

“While not a surprise, this decision is deeply disappointing and could cripple HIV prevention efforts, particularly among communities of color and communities of poverty,” said National Minority AIDS Council Executive Director Paul Kawata in a statement. “For many people at higher risk of HIV, employer-provided insurance is often their only way to access these vital medications. This decision has the potential to cut off millions of Americans from the life-protecting medications they need.”

The American Medical Association, along with 61 leading medical organizations, signed a joint statement that highlighted this threat to preventive services. 

“With an adverse ruling, patients would lose access to vital preventive health care services, such as screening for breast cancer, colorectal cancer, cervical cancer, heart disease, obesity, diabetes, preeclampsia, and hearing, as well as well child visits and access to immunizations critical to maintaining a healthy population,” the statement read.

Wednesday’s decision did not provide specifics on how the ruling will be enforced. O’Connor found that appointments to the Preventive Services Task Force (PSTF), an advisory body convened by HHS that recommends a wide range of preventive services to be covered under the ACA, were in violation of the Appointments Clause but did not offer clarity on its future.

While the ruling did not vacate the mandate or issue a nationwide injunction, the court could issue a decision on that status soon. O’Connor requested that both sides file additional briefs on a range of ongoing issues, including the scope of relief for the plaintiffs and claims related to a mandate for contraception, by Friday. 

HHS has yet to announce whether it will appeal the decision.