Yesterday, the Supreme Court heard oral arguments in Kennedy v. Braidwood Management, which could upend the Affordable Care Act (ACA)’s preventive care requirements as we know them. The case is, on its face, about separation of powers and the delegation of authority around preventive health services under the ACA. But like every challenge conservatives launch against the ACA, it is about so much more.

Here’s how we know that the ACA is a landmark legislative achievement—aka, that bitch. Conservatives have spent more than a dozen years pitching every harebrained legal theory they have to challenge it, only to lose time and time again, with notable carve outs the Court allowed around the birth control benefit for certain employers. This latest challenge—brought by one of the ghouls behind Texas’ notorious abortion bounty-hunter bill, SB 8—seems likely to suffer the same fate.

The ACA requires health insurers and group health plans to cover “preventive health services” at no additional cost to the patient. Those services are determined by the U.S. Preventive Services Task Force (PSTF), a group of 16 volunteer experts in their fields, who recommend which health services should be considered preventive care under the ACA. The Public Health Service Act mandates task force members and their work to be independent and free of “political pressure.” The task force’s recommendations for required preventive-care services include coverage for cancer screenings and pre-exposure prophylaxis (PrEP), the drug that prevents HIV transmission.

The task force, and its origins and structure, had operated largely unchallenged by conservatives since the ACA’s passage and despite all their other complaints about the ACA. But then, the first Trump administration successfully packed the federal courts full of ideologues, all but guaranteeing that any wild legal theory floated by conservatives would ultimately find a home with at least five justices at the Supreme Court.

And that’s how the Braidwood challenge came to life.

In 2020, two Christian-owned businesses, along with four individuals, filed a lawsuit in a Texas federal court before notorious ACA-hater Judge Reed O’Connor seeking to block enforcement of the ACA’s preventive services requirements, including PrEP coverage. Those plaintiffs, represented by Jonathan Mitchell (yes, that Jonathan Mitchell), argued the ACA’s preventive services requirements are unconstitutional because they violate the Appointments Clause, which gives the president the power to appoint federal officers. The plaintiffs claim the PSTF volunteers are not properly appointed government officials and therefore cannot make rules regarding services that must be covered under the ACA, such as PrEP.

They also argued that the PrEP requirement violated their religious rights under the Religious Freedom Restoration Act (RFRA), because they believe the drug coverage “encourage[s] homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman” in conflict with their sincerely-held religious beliefs.

RFRA is the same federal law private employers used to undermine the ACA’s birth control benefit more than a decade earlier in Hobby Lobby v. Burwell.

Unsurprisingly O’Connor sided with the plaintiffs in Braidwood, ruling in 2022 that the task force recommendations violated Braidwood Management’s rights under RFRA and that the task force’s recommendations were unconstitutional under the Appointments Clause. The Biden administration appealed that ruling to the Fifth Circuit, which issued its own mess of a decision in 2023, largely upholding O’Connor’s decision. The Biden administration filed a petition for certiorari asking the Supreme Court to review the Fifth Circuit’s decision, which the justices granted earlier this year.

Despite the spicy RFRA claims in the underlying proceedings, Monday’s oral arguments before the Supreme Court revolved around questions of the separation of powers and whether task force members are “inferior” officers, not religious objections to PrEP coverage. That’s because—thankfully—the RFRA question wasn’t before the Court to review. But it’s irresponsible to discuss this latest challenge to the ACA without acknowledging that Braidwood is, at its core, another example of how the conservative legal movement has spent over a decade manipulating the courts to try accomplishing something its compatriots in Congress have yet to achieve: repealing and replacing the ACA.

The closest conservatives have gotten to a win against the ACA was through their successful challenges to its birth control benefit in the Hobby Lobby, Zubick v. Burwell, and the Little Sisters of the Poor v. Pennsylvania cases, each of which chipped away at the accommodations process for avoiding contraception coverage required under the law. And in some ways, Braidwood was teed up to be another accommodations-style fight, this time over PrEP. But, because of the narrow scope of review before the Court, the fight over whether covering PrEP is subject to religious objection has been avoided—for now.

If the Court rules in favor of Braidwood, private health insurers would no longer be required to cover, without cost sharing, those preventive services recommended by the task force after 2010 when the ACA was signed into law. That means care and medications like statins to prevent heart disease, lung cancer screenings, and PrEP could be subject to copays, deductibles, or coinsurance, potentially deterring access to these services.

But a win for the federal government may not be the win health-care advocates could hope for, either. That’s because we have the Trump administration and the Make America Healthy Again movement setting federal health policy based on junk science, eugenics, and social media influencer campaigns.

The good news from Monday’s arguments is that a majority of justices on the Roberts Court seemed inclined to toss this latest challenge to the ACA away and outright reject Mitchell’s Appointments Clause arguments. That would mean the task force remains in place and can continue to issue recommendations.

The bad news is that it may come at the cost of granting Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. clarified—and maybe even expanded—control over implementing PSTF recommendations. That’s in part because the Trump administration argued (as had the Biden administration before it) that the HHS Secretary has the power to remove task force members at will, as well as to review the recommendations they issue. And during oral arguments, the justices picked up on this point specifically, with Justice Amy Coney Barrett noting that Mitchell was asking for a “maximalist” interpretation of the statutes to make his Appointments Clause case fit.

If Barrett’s point holds and becomes consensus among the Court’s conservatives, then the task force—and its recommendations—will continue to exist under law, and the conservative legal movement will have lost yet another ACA challenge before the Roberts Court. But politically? That’s less clear. Given Kennedy’s past statements on HIV generally, it is reasonable to think he could change the task force’s membership in ways that would significantly alter its recommendations moving forward.

In that sense, Braidwood could wind up being less a case about the resilience of the Affordable Care Act, and more about conservatives’ win-at-any-cost long game against it.