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A federal judge in Texas agreed on Wednesday with plaintiffs -- a handful of employers in the state -- that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively scrapping a central tenet of the Affordable Care Act (ACA).

Under the ACA, most health plans are required to pay for a range of -- including cancer screenings, well-child visits, and routine vaccinations -- without cost-sharing.

The ruling was issued by Judge Reed O'Connor -- the same conservative judge who famously ruled that the ACA was unconstitutional in 2018 before the Supreme Court reversed his decision in 2021 -- and is certain to incite a backlash from organized medicine. It is also expected to be appealed by the federal government.

O'Connor's decision came in response to Braidwood Management v. Becerra (formerly ) in which the plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs. While the lawsuit would eliminate the mandate for all preventive services, some plaintiffs appeared most concerned about services related to reproductive and sexual health.

One plaintiff, Steven Hotze, MD, a family medicine doctor according to , argued in that he did not want to pay for employer insurance that includes coverage of PrEP, "because these drugs facilitate or encourage homosexual behavior" and are contrary to his "sincere religious beliefs."

Four plaintiffs also argued that they "do not need or want contraceptive coverage in their health insurance... [and t]hey do not want or need free STD [sexually transmitted disease] testing covered by their health insurance because they are in monogamous relationships with their respective spouses," the lawsuit stated.

"Each of these plaintiffs is a Christian, and they are unwilling to purchase health insurance that subsidizes abortifacient contraception or PrEP drugs that encourage and facilitate homosexual behavior," the lawsuit continued.

The lawsuit also argued that the preventive services mandate is unconstitutional because it relies on requirements crafted by both federal and non-federal employees -- for example, the Advisory Committee on Immunization Practices and the U.S. Preventive Services Task Force -- whose members were not chosen by the president nor were they confirmed by the Senate.

The 2020 lawsuit was filed by Jonathan Mitchell, an attorney in Austin, Texas, who led the way in establishing Texas's 6-week abortion ban, according to The Tribune.

Lisa Lacasse, president of the American Cancer Society Cancer Action Network, blasted O'Connor's decision.

"Before the passage of the Affordable Care Act, high costs and unclear coverage were repeatedly cited among the top reasons people delayed or skipped screenings. We cannot risk returning to a system wherein every individual has to interpret their complex insurance plans to determine if a recommended mammogram will be covered or to determine how much their colonoscopy may cost," said Lacasse in a press statement.

"We strongly urge the government to swiftly appeal this ruling. Cancer patients, survivors and all those at risk for the disease cannot face undue barriers around cost and coverage of these services," she added.

The American Medical Association and dozens of other physician groups warned back in July that "[w]ith 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, diabetes, preeclampsia, and hearing, as well as access to immunizations critical to maintaining a healthy population."

Rolling back this access, the groups stated, "would reverse important progress and make it harder for physicians to diagnose and treat diseases and medical conditions that, if caught early, are significantly more manageable."

Joyce Frieden, Washington editor, contributed to this article.

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