In a dramatic move with significant political and economic implications, a majority of the U.S. Supreme Court on Thursday (June 28) voted to uphold President Barack Obama's landmark health care reform law. The vote, at least in regard to the key conflict – the individual mandate – was 5-4, with Chief Justice John Roberts writing the opinion and joining the four justices on the liberal wing.

The decision is a big relief to people with costly illnesses, including people with HIV or breast cancer. It is an enormous political victory for the Obama administration, because health care reform was Obama's signature domestic achievement thus far in his first term. And it creates an awkward issue for presumptive Republican presidential nominee Mitt Romney to negotiate. Romney worked for a similar plan for Massachusetts, when he was governor, but has since joined the majority of Republicans in arguing vigorously against requiring citizens to buy coverage or pay a "tax" for not doing so.

The Affordable Care Act's individual mandate requires every citizen, by 2014, to either buy health coverage or pay a penalty that helps mitigate the burden on the health care system when they seek medical care without insurance.

All three of the nation's major LGBT legal groups had signed onto a brief in support of the ACA, noting that 30 percent of people with HIV are not able to obtain health insurance.

Among other things, the ACA prohibits insurance companies from limiting or refusing coverage for a person with HIV, breast cancer, or any other disease. It also prohibits insurance companies from dropping a person's coverage after the person became ill.

Justice Anthony Kennedy, writing for the dissent, said he believes the entire law is unconstitutional. He was joined by the court's conservative wing, including Justices Antonin Scalia, Clarence Thomas, and Samuel Alito.

Lambda Legal Defense and Education Fund, Gay and Lesbian Advocates and Defenders, the National Center for Lesbian Rights, the National Center for Transgender Equality, and others submitted a joint brief in support of the ACA. They argued the law ensures health coverage for people with HIV and, in doing so, stems the spread of the virus to others. That, they said, also helps contain the enormous burden that HIV infection puts on the health care system.

The 30-page brief was one of more than 130 briefs filed in HHS v. Florida and several other lawsuits seeking to strike down the ACA, signed into law two years ago by Obama.

The LGBT groups' brief, like most media reports, focused on the individual mandate that everyone purchase health coverage. Under the ACA, with some exceptions (including religious-based objections and poverty), everyone would have to obtain health coverage starting in 2014. Those who failed to do so would have to pay one percent of their income annually as a penalty. Over the years, the penalty rises, but there are limits to how high it can go.

Reaction

With the individual mandates, argued the LGBT groups' brief, "thousands of lives – and billions of dollars – could be saved each year, and the HIV/AIDS epidemic could be dramatically curbed."

Carl Schmid, deputy executive director of the AIDS Institute, said his group was "extremely pleased" with the upholding of the ACA.

Other LGBT agencies praised the court's decision.

"The Affordable Care Act includes several provisions that will directly help ensure that transgender people have fair access to competent care, including prohibiting insurance plans from discriminating based on gender identity," Masen Davis, executive director of the Transgender Law Center, said in a statement emailed to supporters shortly after the court's decision was announced.

The San Francisco AIDS Foundation also hailed the ruling, saying that the court "delivered a huge victory to nationwide efforts to establish a health care system that works for everyone, including the 1.2 million people living with HIV/AIDS in the United States."

"For the first time in the history of the epidemic, the ACA will dramatically expand health care access to people previously considered uninsurable, including millions of Americans living with HIV/AIDS and other serious illnesses," Neil Giuliano, CEO of the foundation, said in a statement.

Chad Griffin, the new president of the Human Rights Campaign, said that the ACA "addresses a number of barriers LGBT people face in obtaining health insurance, from financial barriers to obtaining affordable coverage to discrimination by insurance carriers and health care providers."

NCLR Executive Director Kate Kendell said that the law creates services and programs that prioritize issues that are crucial to LGBT people. For example, the ACA grants the Department of Health and Human Services the authority to collect data about demographic information for the purposes of targeting health disparities in certain communities. According to NCLR, HHS Secretary Kathleen Sebelius has already announced that her department will exercise its authority under this provision to collect data on sexual orientation and gender identity in addition to the already required categories of race, ethnicity, primary language, sex, and disability status.

The court upheld other points of contention in the law, including whether states can be required to cover the expanded number of people qualifying for Medicaid under the ACA. Some states opposed that expansion, saying it unfairly increases the state's obligation to share the Medicaid costs. The majority opinion said the federal government could not withdraw existing Medicaid funding from states that were unable to fund the expanded pool.

NCLR pointed out that the court's narrow reading of the Medicaid expansion "may have an adverse impact on the ability of low-income people to access care, which will disproportionately affect the LGBT community." Low-income people in states that refuse to participate "will face continued barriers to obtaining needed care," the agency pointed out.

Nonetheless, Kendell said Thursday's decision was an important first step.

"Today is a banner day for all Americans who care about fixing our broken health care system," Kendell said in a statement.

Other court actions

In other Supreme Court news this final week of the term, the high court voted 5-3 (with Justice Elena Kagan recusing herself) to strike down three provisions and at least temporarily sustain one provision of Arizona's controversial immigration law. Lambda Legal said the one provision retained – the so-called show your papers portion allowing law enforcement officers to stop any person they suspect is in the United States without the federal government's permission – is especially harmful to LGBT people.

"LGBT immigrants and LGBT people of color remain particularly vulnerable because this provision ... requires police to stop and question people based on their appearance," said Lambda Legal, in a statement released about the decision. "The LGBT community knows all too well how easily people who are perceived to 'look different' or 'act different' can be singled out for harassment and persecution."

Lambda Legal said it would join other groups in staging a constitutional challenge to the provision. The Supreme Court did not declare the provision to be constitutional but said it could be enforced until such time as a court does rule it to be unconstitutional.

The majority struck down three other controversial provisions of the Arizona law as overstepping state authority and encroaching on the purview of federal authority.

Kennedy wrote the majority opinion, which was joined by Roberts and Justices Ruth Bader Ginsburg, Stephen Breyer, and Sonia Sotomayor.