The Affordable Care Act, which extended health coverage to more than 20 million Americans after its 2010 passage, has once again survived, following a 7-2 decision from the Supreme Court. 

The case, known as California v. Texas, looked at whether the ACA could still stand if one of its provisions, the individual mandate — which required that people have coverage or pay a penalty — had been undone.

It’s a ruling with profound implications for women and LGBTQ+ people, who disproportionately benefited from the law’s anti-discrimination protections. The decision also will have a broad impact on President Joe Biden’s proposed health care agenda, which would build on the law’s coverage expansions and insurance regulations. 

Justices voted to uphold the law, arguing that the plaintiffs — a group of Republican-led states headed by Texas — did not have standing to sue. Justice Stephen Breyer, one of the court’s liberal justices, wrote the opinion. 

The case stemmed from President Donald Trump’s 2017 tax law, which set the mandate’s financial penalty to $0. The change, a group of states led by Republicans argued, meant that the rest of the ACA could be undone without that provision. The states argued they faced financial harm from having to continue to enforce the law.

But seven justices — the court’s liberal trifecta, Chief Justice John Roberts and Justices Brett Kavanaugh, Amy Coney Barrett and Clarence Thomas — said that argument was unconvincing, and that neither the states nor individuals suing suffered any unique, direct injury from the law, even after the mandate had been set to $0. That, they wrote, meant the states didn’t have legal grounds to challenge the ACA.

Health policy researchers have long pointed to the ACA as a gender equity law, citing in particular its prohibition on insurance charging people more or denying coverage because someone had a preexisting medical condition. Women were more likely to have such conditions, meaning that before the law passed, they paid far more for coverage. Being transgender was also often treated as a preexisting condition. The law also banned discrimination in health care based on someone’s gender, a protection that particularly benefited LGBTQ+ people.

Other ACA reforms have also greatly impacted women and LGBTQ+ people. The law instituted new regulations on private insurance plans, requiring them to cover contraception without any out-of-pocket costs, as well as pregnancy-related care, prescription drugs and mental health care. Women and LGBTQ+ people have higher rates of anxiety and depression — a disparity exacerbated by the coronavirus pandemic — and are more likely to forgo medication because of cost barriers.

The law also enabled states to expand eligibility for Medicaid, the government insurance program for low-income people and the nation’s biggest source of coverage for pregnant people. Research has found that states that opted into the expansion saw particular benefits for pregnancy-related health by ensuring that people could more easily keep insurance even after they gave birth. Medicaid expansion has also disproportionately benefited transgender people, who face far higher rates of poverty and were mostly ineligible for its coverage prior to the ACA’s passage.