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Federal Judge Rules HIV Drug Mandate Violates Religious Freedom

Tuesday, September 27, 2022

A federal district court in Texas ruled that the Affordable Care Act’s (ACA) requirement that health plans cover HIV pre-exposure prophylaxis (PrEP) without cost-sharing violates the plaintiffs’ religious freedom on September 7, 2022. The court also ruled that one way for determining the types of preventive care that must be fully covered by health plans is unconstitutional, possibly setting up another battle over the ACA’s legality.

Preventive Care Mandate

The ACA requires most health plans to provide coverage for certain preventive care services without cost-sharing (that is, without deductibles, copays, or coinsurance). These preventive care services include evidence-based items or services that have a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force (PSTF). In 2019, the PSTF released an “A” recommendation for PrEP for individuals who are at high risk of HIV acquisition, which means that health plans must cover HIV PrEP without cost sharing.

Federal Court’s Ruling

A group of individuals and businesses sued the U.S. Department of Health and Human Services (HHS) to challenge the ACA’s preventive care mandate under the Religious Freedom Restoration Act (RFRA) and the U.S. Constitution.  The district court ruled that the HIV PrEP mandate violates the RFRA, siding with plaintiffs who argued that this coverage compels behavior that violates their religious beliefs, such as homosexual behavior, drug use, and sexual activity outside of marriage. The court also ruled that using the PSTF’s recommendations as a coverage mandate violates the Constitution because PSTF’s members are unconstitutionally appointed but reserved its ruling on the appropriate remedy.

In 2018, this same federal judge ruled that the entire ACA was unconstitutional based on the law’s individual mandate to purchase health insurance. The Supreme Court overturned that ruling in 2021. HHS is expected to appeal this decision.


  • Preventive Care Guidelines – The district court ruled that a part of the process for determining the types of preventive care that must be covered without cost-sharing violates the U.S. Constitution.
  • HIV PrEP – Current preventive care guidelines require most health plans to cover HIV PrEP without cost sharing. A federal district court ruled that this coverage mandate violates the plaintiffs’ religious freedom.

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