A federal judge on Thursday overturned a portion of the Affordable Care Act that makes preventive services, such as some cancer screenings, free to enrollees, a decision that could affect health insurance policyholders nationwide.

The decision from the U.S. District Court for the Northern District of Texas could open the door for insurers or employers to reinstate copayments for some of those preventive services, although many may be reluctant or unable to do so, at least immediately.

The ruling by U.S. District Judge Reed O’Connor builds on a September judgment in which he also said the ACA requirement that employers cover pre-exposure prophylaxis treatment to prevent HIV violates the Religious Freedom Restoration Act.

His ruling is the latest shot in the legal battle over the ACA. “Previous cases threatened the very existence of the law and fundamental protections. This decision does not do that,” said Larry Levitt, KFF executive vice president for health policy. But “it strikes down a portion of the law, albeit a very popular one, that is used by a lot of people.”

It is almost certain to be appealed, possibly by both sides: the conservative groups that brought the case and had hoped the decision would be broader, and the Biden administration, which supports the ACA.

“The stakes are really high,” because the ultimate decision could affect millions of Americans, said Andrew Twinamatsiko, associate director of the health policy and the law initiative at the O’Neill Institute at Georgetown University.

“Americans should have peace of mind there will be no immediate disruption in care coverage,” said Matt Eyles, president and CEO of AHIP, the health insurance industry’s leading lobbying group.

Now, the Department of Justice must decide whether to seek an emergency order putting the ruling on hold during the appeal process.

The decision could affect the no-copay screenings and similar preventive services that most insured Americans have as part of their health plans. But consumers may see little impact initially.

“The word prevention appears a couple hundred times in the ACA,” said Timothy Jost, law professor emeritus at Washington and Lee University School of Law, who closely follows the ACA. “Part of the idea of the ACA was we thought to try to prevent disease or at least identify it earlier when it’s more curable.”

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