Health Care Access and Coverage for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community in the United States: Opportunities and Challenges in a New Era

Published: February 21, 2014

 By many measures, societal acceptance and support of LGBT rights in the United States have increased significantly in the last decade, especially in the last couple of years.  Perhaps most notably has been the increase in public support for legalization of same-sex marriage, as well as gains in legal recognition, including the June 2013 Supreme Court decision which overturned a major portion of the Defense of Marriage Act (DOMA), resulting in federal recognition of same-sex marriage in the U.S.

 
At the same time, however, a majority of states continue to impose bans on same-sex marriage and most offer no protections based on sexual orientation and gender identity in the areas of employment and housing, and many LGBT individuals report having experienced some form of discrimination based on their sexual orientation or gender identity.  Ongoing discrimination, violence, and stigma compromise access to needed health services by LGBT individuals.
 
In a new issue brief  from the Kaiser Family Foundation, we examine what is known about LGBT health status, coverage, and access in the U.S., and look at recent changes within the legal and policy landscape which serve to increase access, in particular, the pivotal impact of the Affordable Care Act (ACA) and Supreme Court’s DOMA decision.  Both have the potential to dramatically reduce the rate of uninsured and make the health system more equitable in LGBT communities, although many outstanding questions remain.
 
Our summary of the data shows the importance of improving coverage and access to care for this community.  Sexual and gender minorities experience worse physical and mental health outcomes and face unique health challenges compared to their heterosexual counterparts.  These include a higher prevalence of HIV, mental illness, substance use, smoking, and other health conditions.  The impact of the HIV epidemic is particularly alarming, with gay and bisexual men accounting for two-thirds of new HIV infections, and studies reporting that more than one in four (28%) transgender women are HIV positive. Because of this impact, the Foundation recently launched Speak Out, a new campaign aimed at raising awareness of HIV in the LGBT community.
 
LGBT individuals also face a number of challenges when trying to access health services, including barriers in obtaining insurance coverage, gaps in coverage, cost-related hurdles, and poor treatment by health care providers.  For example, a recent survey found that one in three LGBT individuals with incomes under 400% FPL are uninsured, a group that could qualify for assistance under the ACA.  Challenges are often greater for transgender individuals who are even more likely to be poor and uninsured than LGB individuals and have often been left out of the system either due to denial of coverage or provider inexperience with their health needs.
 
The ACA and the Supreme Court’s DOMA ruling will help mitigate some of these challenges.  The ACA extends coverage to millions who are uninsured through the expansion of Medicaid (in states that choose to expand), as well as the creation of new federally subsidized health insurance marketplaces in each state, and it includes non-discrimination protections on the basis of health status, sexual orientation, and gender identity.  The DOMA ruling has resulted in federal recognition of all legally married same sex couples, including health coverage for same sex spouses of federal employees and the workplace protections of the federal Family Medical Leave Act (FMLA).
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