Stick with me. How does a 40-plus-year crusade by a virulently anti-gay, racist physician in Texas—one who hawks quack cures and was charged in 2022 with aggravated robbery and organized criminal activity in a bizarre and fake election dispute—end up endangering access to mammograms, colorectal and cervical cancer screening, folic acid supplementation for pregnant women, diabetes screening, and drugs to prevent HIV infection? And where does Robert F. Kennedy Jr. come into this?

Let me introduce you to Steven Forrest Hotze. If you were writing a movie script about this guy and told his story straight-up without embellishment, you’d be accused of caricature. Thankfully, Sam Levin wrote a profile of Hotze for The Guardian last May. My short description above doesn’t do justice to this man’s drama.

But before we get to the threat Hotze poses to the health of the majority of American adults, I have to introduce you to another character: Judge Reed Charles O’Connor of the United States District Court for the Northern District of Texas, the go-to bench for conservative plaintiffs seeking favorable rulings for conservative causes. Judge O’Connor reliably returns judgments favoring right-wing litigants, and has teed up major cases for the ever-more-radical Supreme Court, including Dobbs v. Jackson Women’s Health Organization, which stripped pregnant people in the US of the constitutional right to abortion.

Hotze and O’Connor have come together in a legal marriage made in hell around a case called Braidwood v. Becerra. Hotze and other plaintiffs argued that providing pre-exposure prophylaxis (PrEP) to prevent HIV to their employees as part of their health insurance, violates the plaintiffs’ religious freedom, as PrEP “facilitate[s] and encourage[s] homosexual behavior,” and mandating the coverage of PrEP forces them to support “sexual promiscuity.”

Never mind that Hotze had no employees who asked for PrEP, and that the case is built on hypotheticals rather than an “injury in fact,”—that is, harm that is “actual or imminent, not conjectural or hypothetical,” which has historically been required to constitute legal standing under previous rulings by the Supreme Court.

O’Connor delivered his ruling in 2022, claiming that requiring private insurers to cover HIV PrEP violated the plaintiffs’ rights under the Religious Freedom Restoration Act. In an analysis published shortly after the ruling, my colleagues and I suggested that even in the most benign scenario:

For every 1% decline in PrEP coverage among US MSM [men who have sex with men], we expect an additional 114 HIV infections the following year. We estimate that, at a minimum, the Braidwood ruling will result in more than 2000 entirely preventable primary HIV infections among MSM—and many more infections in other populations at high risk of HIV transmission—in 1 year alone.

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And here is where it all gets worse. In his ruling, O’Connor didn’t simply go after HIV PrEP. He went after the US Preventive Services Task Force (USPSTF), the federal panel that made the binding recommendation to insurers to cover PrEP. O’Connor loves to hate the ACA—he tried to strike it down in its entirety in 2018—and in his Braidwood ruling, he decided that the USPSTF was improperly established and thus that all the preventive services mandates recommended by the task force under the ACA were all null and void. (Read Elie Mystal’s piece in The Nation from March 2023 for the details.)

All of this was in limbo as O’Connor’s initial ruling was appealed to the Supreme Court. The court handed down the last word on this case, now called Kennedy v. Braidwood Management, just a few weeks ago, as the Kaiser Family Foundation reported:

On June 27, 2025, the U.S. Supreme Court issued the opinion for Kennedy v. Braidwood Management, finding that the ACA requirement that most private insurers and Medicaid expansion programs cover preventive services recommended by the United States Preventive Services Preventive Task Force (USPSTF) with no cost-sharing is constitutional. In its decision, the Court affirmed that USPSTF members are appointed constitutionally, and the Secretary of Health and Human Services can remove USPSTF members at-will and directly review and block Task Force recommendations before they take effect.

Dodged a bullet there, right? Not so fast. It’s that last sentence that is the coup de grâce. The court gave Robert F. Kennedy Jr. the right to remove USPSTF members at will and rescind the panel’s recommendations by fiat. And he may do just that.

Less than two weeks after the SCOTUS ruling, RFK Jr. abruptly canceled a USPSTF meeting set to occur that week. It’s clear that the right still has the task force in its crosshairs, as The American Conservative published a piece the very same day called “Time for Kennedy to Kill the USPSTF.” What is likely to happen now is that the USPSTF will be “ACIP”-ed. In other words, as he did with the Advisory Committee for Immunization Practices (ACIP), Kennedy is likely to make a clean sweep of current members and replace them with his cronies, unqualified and conflicted.

While the task force will still be there in name, its credibility—based on both the vigorous vetting process of its members and the detailed, rigorous review of evidence that takes years to complete—will be shot. As with ACIP, the new members are unlikely to go through any real selection process, and as with the recent ACIP recommendations on vaccines press their own opinions as recommendations against scientific fact.

More worrisome is that these charlatans will now have their thumbs on the scales of what gets paid for by insurers in the United States. Think of someone like RFK Jr. adviser Calley Means, who rails against the “corrupt” US healthcare system while hawking dietary supplements, herbal remedies, and other wellness products on the side. Imagine him or any number of similar people in RFK Jr.’s orbit on the USPSTF. The grift is strong with these people.

The USPSTF’s recommendations are important for insurers and coverage of a wide set of preventive interventions, but also represent crucial guidance for primary care physicians across the US. Breaking this trust will have terrible consequences. My concerns are not just my own. Three former chairs of the USPSTF have spoken out about recent events: “What we do know is that it is vital that the task force is preserved—the lives of people across the country depend on it.” I’d go further, undermining the task force—even if it is preserved in name—will similarly endanger the health of all Americans.

Hotze and O’Connor must be pleased with themselves. They put all this in motion five years ago. While HIV PrEP and other prevention interventions may have been spared in theory from the axe, now the entire edifice of preventive services in the US is reliant on the whims of RFK Jr. It’s enough to make you sick.

My colleagues at Stanford earlier this year put these risks in stark perspective. For those adults on employer-sponsored health insurance, close to a third (and close to half among women) were receiving at least one intervention at no cost under the ACA mandate for preventive services recommended by the task force.

Back in Texas, where Hotze and O’Connor reside, more than 3 million people have benefited from these no-cost services through their health insurance. This is the gift Hotze and O’Connor have brought home to the Lone Star State with them from their journey. In their zealotry and fervor, they are pulling down the house all around them. The suffering these men will cause is their legacy.