LGBT Community Hails Supremes' Obamacare Decision

Gay activists and organizations are praising the Supreme Court's recent 5-4 decision upholding most of President Barack Obama's Affordable Care Act, better known as Obamacare. While the media has emphasized that the ACA will eventually cover 30 million uninsured Americans, it also ensures that those with preexisting conditions - including having contracted HIV, the virus that causes AIDS - can receive coverage. Even so, some warn that Medicaid will not cover those in states that reject the voluntary expansion in that program.

"The Supreme Court's decision means millions of Americans, including many LGBT people and their families, will be better served by our nation's health care system," said Human Rights Campaign President Chad Griffin in a recent statement. "The Affordable Care Act addresses a number of the barriers LGBT people face in obtaining health insurance, from financial barriers to obtaining affordable coverage to discrimination by insurance carriers and health care providers."

Chief Justice John Roberts - who consistently sides with the conservative wing - wrote the majority opinion. Roberts and four other justices upheld as constitutional the so-called individual mandate that everyone buy health insurance or pay a fine. They concluded, however, that it was valid not as an exercise of Congress' power to regulate commerce but to tax.

The ACA gives the Department of Health and Human Services the authority to collect demographic data to target inequity in certain communities, and HHS Secretary Kathleen Sebelius has announced that the agency will collect data on sexual orientation and gender identity. "The Affordable Care Act may represent the strongest foundation we have ever created to begin closing LGBT health disparities," she said.

Obamacare's biggest benefit, however, is the creation of a market for those who cannot afford health care, HRC Legal Director Brian Moulton told EDGE. It will also help people who can't get coverage via partner benefits.

"Insurance companies will be barred from discriminating against LGBT people, who will be able to feel assured that if they have applied for insurance through these plans they can't be denied access for who they are," Moulton added.

Good News for the Transgendered

The transgender community is another beneficiary of the ACA, according to Moulton.

"They won't get turned away from signing up for the plan or for presenting as female when the name on all their info is their pre-transition name," Moulton said. "Many trans people are excluded from insurance because of being trans - because insurance companies think it means they will have all kinds of medical issues. So this is a big step toward transgender individuals having access."

Obamacare outlines several ways that the transgendered can be discriminated against, according to Executive Director Mara Keisling of the National Center for Transgender Equality. The rules dictate that insurance exchanges can't make determinations based on sexual orientation or gender identity. Recent court cases have defined sex discrimination to include trans people.

Like others, the trans community will benefit from the elimination of a deductible on preventative care, no lifetime cap and more funding for community-based health clinics.

"This is really important because it's the way that most trans people seek care," Keisling told EDGE. "These clinics are more culturally competent to treat trans people."

The ACA's Medicaid expansion is also a boost for the transgendered, who are four times as likely as the general population to be living in poverty.

"They are more likely to be unemployed or underemployed, and more likely to have to work multiple part-time jobs because of discrimination," Keisling said. "That means they are less likely to have insurance through employers."

Helping Those With HIV

Obamacare also lets trans people with HIV get into Medicare earlier, Keisling noted. "Anything good for PLWHAs is good for all LGBTs. Does it totally fix the health care system? No, but it is very positive."

While its total number of cases is small, the transgender community has one of the highest rates of HIV transmission.

"It is important to mention when talking about LGBT that you are also talking about the T," said Kali Lindsey, chief lobbyist for the National Minority AIDS Council. "The ACA would be incredible for gay men and lesbians' access to health care, but the trans community has never gotten the health care they need because of gender nonconformity."

Male-to-female trans people have been relegated to the "male" column under Medicaid and never received preventative services, Lindsey said. Now the transgender and gender-reassignment designations that were considered preexisting conditions won't disallow access to care.

Medicaid Expansion Leaves Some Stranded

In the past, people with HIV could not qualify for health care coverage until their T-cell count dropped below 200, a point that progresses to AIDS. The 2.1 million people in the United States with HIV can now receive treatment much sooner, which means stemming the onslaught of full-blown AIDS.

"Individuals who could have been benefiting from health care and averting future transmissions to sexual partners were not getting treatment," Lindsey told EDGE. "Essentially, if one partner is negative and one is positive, and viral therapy can suppress the virus, it reduces their infectiousness by 98 percent."

The downside of Obamacare is the proposed insurance exchanges, according to Lindsey. Coverage will become more affordable for those making from $15,000 to $43,000 a year, and expanded Medicaid will be offered to those making less than $15,000. But many with HIV have incomes that fluctuate between eligibility for Medicaid and for the exchanges. That means changing their doctor, which means a bigger chance of missed appointments, overlooked diagnoses and poor adherence.

"This is one of the ways that health care gets fragmented, through errors and duplication," said Lindsey.

"The other thing we have to look at with people of color and Medicaid is that Southern states have already articulated that they don't want to implement the ACA enhancements," Lindsey added. "People of color within these jurisdictions already have the most alarming incidence rates and a woefully underfunded health care infrastructure. And while we are now talking about giving people access to care, because the Supreme Court decided that Congress can't compel states to use Medicaid programs, there is no guarantee that those individuals in Southern states will get any better access to care."

Helping the Old & the Young

Income disparity extends to homeless LGBT youth, who most often lack marketable job skills, said Carl Siciliano, founder and director of the Ali Forney Center, a shelter for homeless LGBT youth in New York City.

"If we don't recognize access to health care as an LGBT issue, it's because we're not prioritizing the poorer members of our community," Siciliano said. "If we don't fight for resources for the poorer members, they get left behind as we gain our acceptance. There has to be a discipline within the LGBT movement where we recognize that the fight for resources for our poorer members is part of our obligation."

On the other side of the age spectrum, the ACA will let LGBT baby boomers pay less for prescription drugs and will increase access to free services to help prevent age-related disease.

"This is a great step in changing the way we care for our aging population, people with disabilities and each other when faced with illness," said Ai-jen Poo, co-director of Caring Across Generations. "Now we can move forward to address the looming challenge of our aging population."

The Log Cabin Republicans, the major LGBT group within what Ronald Reagan called the "big tent" of the GOP, complain that Obamacare is another tax burden on Americans suffering in the worst economy since the Great Depression of the 1930s. As part of the loyal opposition, Log Cabin members are following their core conservative principles of rejecting government solutions and what they consider coercive taxes.

According to Log Cabin Programs Director Casey Pick, Obamacare will ultimately be a negative for LGBT people because the Tax Equity for Health Plan Beneficiaries Act was stripped out of the law.

"What that means," Pick said, "is if your employer offers spousal benefits to heterosexual partners, the IRS doesn't tax it, but if your employer offers it to domestic partners, the IRS calls it 'additional income' and taxes it to the tune of thousands of dollars to employees and thousands in payroll tax to employers." Obamacare will actually discourage employers from offering equal benefits to LGBT employees, she asserted.

When a reporter pointed out that the ACA was modeled on Mitt Romney's pioneering idea while the GOP presidential candidate was governor of Massachusetts, Pick replied: "There's a big difference between a federal mandate that affects the entire country and the longstanding responsibility of a state to have jurisdiction regarding health or police powers. The founders intended the states as a laboratory for different policies."

The House's recent vote to repeal the ACA was clearly symbolic, as the Democratic-controlled Senate will never go along. It's possible, however, that the Supreme Court decision would be rendered moot if Romney wins and the GOP retakes the Senate and consolidates its power in the House.

LGBT health advocates stand firmly on the side of implementation of the far-reaching law. Affordable health care for all, without exemptions based on sexual orientation, gender identity or preexisting conditions, is far more important to them than potential costs.