JOHN YANG: The latest legal battle over the Affordable Care Act centers on its requirement that private health insurance fully cover preventive services like cancer screenings, vaccine nations in birth control.

Also on that list, drugs that prevent HIV infection called pre-exposure prophylaxis, or PrEP.

The retail price of PrEP can be as much as $6,000 for a 90 day supply.

That puts it out of reach for many of those who benefit from it but don't have insurance.

Shefali Luthra is a health reporter at the 19th News.

She focuses on the intersection of gender and health.

Shefali, first of all, tell me about PrEP.

How effective is prep?

SHEFALI LUTHRA, The 19th: PrEP is incredibly effective.

Studies put it at more than 90 percent effective in preventing HIV.

Some would call it a wonder drug, and it's not entirely wrong.

It has really transformed what it means to sort of live in our society, especially if you are in a group that is high risk for contracting HIV.

Taking PrEP largely in a daily pill, although there is a new injectable form as well, can really allow you to live a life that is much safer, much freer of risk, and just without the fear of contracting a disease that in the past has been incredibly dangerous.

JOHN YANG: Given those benefits.

Given what you just said, PrEP, the pills have been around for about a decade now, but the CDC estimated in 2020 that only about a quarter of the people who would benefit from PrEP are actually on PrEP.

Why that gap?

SHEFALI LUTHRA: There has been a historic number of reasons as to why PrEP uptake wasn't as high and still isn't as high, frankly, as how public health experts would like a large one.

In the past, as you mentioned, was the price tag.

The pills taken for PrEP have been very expensive.

There are new generics on the market that bring down the price, but without insurance that covers the medication, it can be prohibitive for many people, especially those who are with lower incomes.

The other sort of challenge that we don't always talk about, but that is really important is outreach.

And there is a lot of really effective outreach in making sure that certain demographics know about PrEP.

This is largely seen as a drug that has been very good at making its way to men who are white and who are gay.

And it often doesn't reach out in the same way to many people who are also at higher risk but aren't considered in that archetype.

And there are large efforts in particular to expand outreach to trans Americans and to black Americans who are at higher risk of HIV and may not be told about Prep by their doctors or may, for other reasons, not consider it as the right drug for them.

JOHN YANG: The other thing that some people talk about is the fact you've got to take a pill every day.

Does the fact this injectable PrEP, which you only get a shot every other month after initial two shots in two months, do you think that would help spread use of this drug?

SHEFALI LUTHRA: I think that's an open question right now.

And we do know that even with the injectable PrEP, you need to have regular visits to a doctor to get the injection, which can be a barrier for folks who aren't that plugged into the healthcare system, who don't have a regular medical professional they see who don't have health insurance.

We also know that the injectable PrEP is still fairly new.

It isn't always covered at no cost by health insurance, unless for some reason you've shown that you cannot take the daily pill.

It seems like a really viable possibility to expand options for people who want to prevent themselves from getting HIV, but I think it's too early to say just how meaningful an impact it could have.

JOHN YANG: As we say, this is the center of a new legal battle over the ACA.

There's a lawsuit that's before the Fifth Circuit Court of Appeals right now, a group wants to knock out the preventive care mandate.

Who's bringing this suit and why do they want it out?

SHEFALI LUTHRA: This group of employers from Texas has challenged the preventive services mandate in court.

They filed it in a court in Texas where the judge is known to be quite hostile to the Affordable Care Act.

It goes to an appeals court that is known for being quite conservative.

And their argument is twofold.

In part, they say the federal government has overstepped its authority in determining certain preventive services that must be covered at no cost by the ACA.

They also claim that they have a religious exemption.

They say that providing insurance to their employees that covers PrEP violates their religious beliefs.

And frankly, the arguments, many legal authorities have told me, are quite steeped in bias against largely gay men in what many have described as homophobic claims that covering PrEP would facilitate or encourage people to have sex outside of a marriage between a man and a woman.

And what was troubling to some is that there is some interest in those legal arguments, although at this point, those are not the main claims as to why PrEP shouldn't be covered.

But right now, what is happening is that the Fifth Circuit Court of Appeals based in Louisiana, is hearing arguments in this case.

They'll issue a decision relatively soon.

But for now, they have said that health insurers must keep covering PrEP and other preventive services at no out of pocket cost to consumers.

JOHN YANG: And if that were to go away, what would it do to not only HIV prevention, but to birth control, to cancer screening and all sorts of other things that fall under that category?

SHEFALI LUTHRA: The contraception question is a little bit tricky because the guarantee for birth control with no out-of-pocket cost comes from multiple variations or multiple facets of the ACA.

But we do know that there could be new costs for consumers, for PrEP, for mental health screenings, for cancer screenings, for all sorts of sort of reproductive health care services that we now take for granted.

And that could suddenly become very expensive for people if they are no longer able to have this preventive services mandate.

That, to be clear, has been in effect for a very long time.

The ACA was passed in 2010, which was more than a decade ago.

JOHN YANG: Shefali Luthra of the 19th News.

Thank you very much.

SHEFALI LUTHRA: Thank you for having me.