Gutting ACA no-cost coverage to affect millions, mostly women

A new study in JAMA Health Forum found that nearly one in three adults received preventive services through the Affordable Care Act's no-cost coverage requirements, which are threatened by a legal challenge being heard by the U.S. Supreme Court.  

What's more, almost half of women in the study's sample received the services between 2018 and 2022. 

The study conducted by researchers at Stanford University and the Harvard T.H. Chan School of Public Health analyzed utilization of individuals aged 15 to 64 years enrolled in employer-sponsored health coverage as of 2018, reported in the Merative MarketScan Commercial Database. 

They tracked utilization across ten preventive services potentially impacted by the legal challenge. Selected services include statin use to prevent cardiovascular disease; preexposure prophylaxis for HIV; medication to reduce breast cancer risk; and new or expanded screenings for breast, cervical, colorectal, and lung cancers and hepatitis B virus, hepatitis C virus and HIV infections. 

No-cost coverage of these services is at risk if the Supreme Court upholds the ruling from a 2022 Texas district court, which deemed the ACA no-coverage requirements as unconstitutional. Specifically, the court took issue with the mandated coverage of services recommended by the U.S. Preventive Services Task Force (USPSTF). 

The Texas district court barred no-cost coverage of services recommended by USPSTF following the ACA's passage in 2010. 

An appeal of the ruling was partially upheld in 2024, and the Supreme Court recently heard the case -- now called Kennedy v. Braidwood -- in April 2025. 

But rolling back the no-cost coverage mandate could affect millions of Americans who rely on it to access preventive services, the study indicated.  

About 39.1 million individuals in the study received at least one of the 10 preventive services without cost-sharing, including more than 3 million in Texas, where the legal challenge of the ACA no-cost coverage mandate originated. 

The most commonly received services included screenings for cervical cancer (23.6 million), hepatitis C virus infection (11.1 million) and HIV infection (10.5 million). 

Researchers also said their findings scrape the lower bounds for utilization of preventive services under the mandate. Some jeopardized services, such as anxiety screenings, were not included because they are hard to track through claims. Tracking individuals covered by employer-sponsored health coverage is also difficult because of changing employment status or data provider participation in MarketScan, which biased total estimates downward, they said. 

"Removing the no-cost coverage requirement would affect millions of individuals who benefit from preventive services across all states," the study concluded. "Potential downstream consequences should be considered, including delayed health care access and increased morbidity, mortality, and disparities." 

Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.