A woman in rural Mississippi drives 90 minutes to a Planned Parenthood for a mammogram. Last year, that clinic closed. She is one of the patients behind the 50-plus health centers that shut down across 18 states in 2025, 23 of them directly because of a Medicaid funding rule. The rule was aimed at abortion. What it actually cut was birth control, STI testing, and cancer screenings for people who had nowhere else to go.

That is what happens when you pull back on free preventive care. People do not find alternatives. They just go without.

I think the federal government should mandate free preventive care coverage. Not because I love mandates, but because the alternative is already playing out in front of us and it is not good.

The Basics Are Not Boring, They Are Just Underfunded

Preventive care is not complicated. A blood pressure check. A mammogram. A colonoscopy starting at 45. An HPV test you can now do at home. These are not cutting-edge interventions. They are the kind of thing your doctor has been telling you to do for 20 years. The ACA made them free because cost was the main reason people skipped them. That logic still holds.

60% of Americans say out-of-pocket medical costs are their top financial worry. The out-of-pocket maximum for a family plan hits $21,200 this year and climbs to $24,000 in 2027. When people are already stretched that thin, a $300 screening feels optional. It is not optional. It is just priced like it is.

The Title X family planning program historically reached more than 5 million low-income patients a year, and 60% of them had no other source of care. Now the federal government is reshaping that program to focus on fertility and family formation instead of contraception and unintended pregnancy prevention. I understand the policy argument. I do not think it survives contact with the 60% who had nowhere else to go.

When Prevention Gets Ideological, Patients Pay

There is a version of the anti-mandate argument I respect. Jon Gruber at MIT has argued that ACA mandates helped control premiums but created other distortions. High deductibles are a real problem. The proposal to let people use HSAs for preventive and primary care without a high-deductible plan attached is worth taking seriously. Markets can do some things well.

But markets work when people have choices. A low-income patient in a rural county with 1 clinic does not have choices. She has that clinic or nothing. When the funding dries up and the clinic closes, the market has not solved anything. It has just made the problem invisible.

Delaware's House Bill 338 wants to lock in insurer coverage for vaccines and preventive services at 2026 federal recommendation levels, regardless of what Washington does next. That is a state trying to hold the floor because the federal government keeps moving it. More states will follow. That is not a health system. That is a patchwork.

The federal government should restore full Medicaid reimbursements to preventive care providers, stop the ideological reshaping of Title X, and keep the ACA's free preventive care mandate intact. Not because it is a perfect system. Because the woman who drove 90 minutes for a mammogram now has nowhere to drive.

Consistency beats intensity in fitness. It beats ideology in public health too.