Microsoft Word - LGBT Health IB

June2021

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ISSUEBRIEF 1

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HP‐2021‐14

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HealthInsuranceCoverageandAccesstoCarefor

LGBTQ+Individuals:

CurrentTrendsandKeyChallenges

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ArielleBosworth,GinaTurrini,SaradaPyda,KieaunaStrickland,

AndreChappel,NancyDeLew,andBenjaminD.Sommers

KEYPOINTS

 IndividualsintheLGBTQ+communityfaceuniquechallengesandbarrierstocare.Expanding

accesstohealthinsurancecoverageisoneimportanttoolinimprovingaccesstocareinthis

population.

 AnalyzingsexualorientationdatafromtheNationalHealthInterviewSurvey(NHIS),wefindthat

uninsuredratesintheLGB+

communityhavefallensubstantiallysincethepassageofthe

AffordableCareAct(ACA),from17.4percentin2013toalowof8.3percentin2016.However,

theuninsuredrateincreasedafter2016.

 WhiletheNHISdoesnothaveinformationongenderidentity,non‐governmentdatasources

suggestsimilar

benefitsoftheACAoncoverageratesamongtransgenderindivi duals.

 Overalluninsuredratesin2019were12.7percentforLGB+individuals vs.11.4percentfornon‐

LGB+individuals,withhigherratesofMedicaidcoveragebutsimilarMarketplaceenrollmentand

lowerMedicareenrollment.

 TheAmericanRescuePlan(ARP)increasedthe

generosityofpremiumsubsidies availableinthe

Marketplace.IfthesameshareofLGB+enrolleeswhohaveMarketplacecoveragehaveazero‐

premiumoptionundertheARPasexistsforallMarketplaceenrollees,weestimatethatroughly

210,000LGB+Marketplaceenrolleesnowhaveaccesstoazero‐premiumplan.



Barriersbesidescoveragealsocontributetopersistentdisparitiesinaccessandhealthoutcomes.

IntheNHIS,LGB+individualsreportbeingmorelikelytodelaycare,lesslikelytohaveausual

sourceofcare,andmorelikelytobeconcernedaboutmedicalbillsthantheirnon‐LGB+

counterparts.Othercontributingfactors

includealackofhealthcareprofessionalsadequately

trainedinprovidingculturallycompetentcare,aswellashighcost‐sharingand/orlackof

coverageforcertainservicesincludinghormonetreatmentsandothergender‐affirmingcare.

_______________________

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Weuseterminologyapplicabletotheoriginalinformationsourceswe cite.WhendiscussingfindingsbasedonanalysisoftheNational

HealthInterviewSurvey(NHIS),whichreportsonindividualswhoself‐identifyasGay/Lesbian,Bisexual,or“somethingelse”,weuse

theterminology“LGB+”.ThoughNHISdoesnotincludequestionsthatallowforidentificationoftransgenderindividuals,many

individualswhoidentifyastransgenderareincludedintheLGB+cohort.LGB+doesnotincludeindividualswhoidentifyas “straight,

thatis,notgay”orthosethatresponded,“Idon’tknow.”Weuse“LGB+”whenreferringtodatafromtheNHIS,andthebroaderterm

“LGBTQ+”inallcontextsotherthanthatspecificdataset.

June2021

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ISSUEBRIEF 2

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INTRODUCTION

LGBTQ+individualshavelongfacedchallengesaccessinghealthinsurancecoverageand qualityhealthcare.Itis

importanttorecognizethattheLGBTQ+populationisdiverseacrossanumberofdimensions.Whilemembers

oftheLGBTQ+communitysharetheburdenofoftenbeingstigmatizedfortheirsexualorientationorgender

identityandexpression,

theirindividualexperiencesvarybyrace/ethnicity,income,andothercharacteristics.

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PoliciesincludingtheAffordableCareAct(ACA)andAmericanRescuePlanAct(ARP)haveexpandedhealth

insurancecoveragetomillionsofAmericans,includingtheLGBTQ+community,butdisparitiesinaccesstocare

andhealthoutcomespersist.ThisIssueBriefanalyzes

nationalsurveydatatodiscussdemographic

characteristicsoftheLGB+community(describedingreaterdetailbelow),recenttrendsininsurancecoverage

forthispopulation,andvariouschallengesandbarrierstocarefacedbythebroaderLGBTQ+community.

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DATASOURCESANDPOPULATIONFEATURES

DatacollectiononLGBTQ+individualsislessconsistentinfederalandstatedatasourcesthanother

demographicinformation.Forinstance,themajorsurveysconductedbytheCensusBureauthatcollect

informationonhealthorinsurancecoveragestatusdonotcollectinformationonsexualorientationorgender

identity.Programenrollmentdatacollected

bytheCentersforMedicare&MedicaidServices(CMS)alsodo

notincludethisinformation.Asaresult,ourunderstandingofhealthcareissuesfacedbythispopulationis

morelimitedthanforothergroups,afactorwhichitselfcancontributetodisparities.

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ThisIssueBriefpresentsdatafromtheNational

HealthInterviewSurvey(NHIS),conductedbytheNational

CenterforHealthStatistics.NHISprovidesdataonLGB+populations.Thissurveydoesnotincludequestions

ongenderidentitythatwouldallowforidentificationoftransgenderpeopl e, whichisanimportantlimitation

ofthisdataset.Itislikelythattherearetransgenderor

othergenderminorityindividualspresentinthedata,

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however,andtheNHISisoneoffewnationally‐representativesurveyswithinformationonsexualorientation,

makingitanimportanttooltounderstandpartsoftheLGBTQ+community.TheNHISsurveyquestion

regardingsexualorientationisonlyaskedofadultsaged18andolder,thepopulationanalyzedinthisreport.

TheNHISsurveyquestionregardinghe althinsuranceasksabouttherespondent’scoveragestatusatthetime

oftheinterview.Weanalyzethemostrecentdataavailable(from2019)formostanalysespresentedbelow,

anddatafrom2013to2019toexaminetrendsinhealthinsuranceandaccesstocareinthis

populationover

time.NHISbegancollectingdataontheLGB+populationin2013;however,coveragegainsforthispopul ation

wouldhavebegunin2010,whentheACAdependentcoverageprovisionwentintoeffect,allowingyoung

adultstoremainontheirparents’plansuntilage26.

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Table1presentsdemographicinformation

fortheLGB+populationintheNHIS,whichrepresentsand

estimated3.1percentoftheU.S.adultpopulation,comparedtothenon‐LGB+population.Onaverage,

individualsidentifyingasLGB+areyounger,havehigherratesofeducationalattainment,andloweraverage

incomesthanindividualsidentifyingasnon‐LGB+.Approximately34percent

oftheLGB+populationisBlack,

Hispanic,AmericanIndian/AlaskaNative,orAsianAmerican/PacificIslander.

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June2021

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ISSUEBRIEF 3

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Table1:DemographicandPersonalChar acteristicsofAdultsbySexualOrientation,2019

 LGB+ Non‐LGB+

Age(Mean,95%ConfidenceInterval) 36.6

(35.5,37.8)

48.2***

(47.9,48.5)

Male 38.1%

(34.4%,42.0%)

48.8%***

(48.1%,49.5%)

Female 61.9%

(58.0%,65.6%)

51.2%***

(50.5%,51.9%)

GenderNotReported 1.5% <0.01%

Race/Ethnicity  

Hispanic 15.3%

(12.5%,18.6%)

16.5%

(15.3%,17.8%)

White(non‐Hispanic) 62.8%

(58.5%,66.9%)

63.6%

(62.1%,65.2%)

Black(non‐Hispanic) 13.9%

(11.1%,17.3%)

11.5%

(10.6%,12.4%)

AsianAmerican/PacificIslander(non‐

Hispanic)

3.5%

(2.4%,5.2%)

5.9%**

(5.3%,6.4%)

AmericanIndian/AlaskaNative(non‐

Hispanic)

1.7%

(1.0%,2.8%)

1.4%

(1.0%,2.0%)

Othersingleormultipleraces 2.8%

(1.7%,4.4%)

1.1%*

(1.0%,1.3%)

Rural(non‐metropolitan) 9.1%

(7.1%,11.6%)

14.6%***

(13.5%,15.7%)

Region  

Northeast 20.2%

(17.2%,23.6%)

17.5%

(16.6%,18.5%)

Midwest 18.0%

(14.9%,21.5%)

21.3%*

(20.2%,22.4%)

South 38.4%

(34.4%,42.5%)

37.8%

(36.4%,39.1%)

West 23.5%

(20.1%,27.2%)

23.4%

(22.2%,24.7%)

Education  

Lessthanhighschool/GED 6.1%

(4.3%,8.4%)

12.3%***

(11.6%,13.1%)

Highschool/GED 21.7%

(18.6%,25.2%)

27.5%**

(26.7%,28.2%)

Post‐highschool 72.2%

(68.4%,75.7%)

60.2%***

(59.2%,61.2%)

Missing 3.3% 0.7%

Married 24.4%

(21.3%,27.7%)

53.5%***

(52.6%,54.3%)

Missing 0% <0.01%

Meanannualfamilyincomeprevious12months(top

codedat$220,000)

$69,613.76

($64,903.51,$74,324.01)

$78,571.47***

($77,227.30,$79,915.65)

Percentofpopulation



3.1%

(2.8%,3.3%)

96.9%

(96.7%,97.1%)

Notes:Resultsaresurvey‐weightedestimatesusingthe2019NHISadultfile.Resultsineachrowdonotincludeitem

non‐respondersinthedenominatorwhencalculatingratesandpercentages.Numbersinparenthesesare95%

confidenceintervals.TestsfordifferencesbetweenLGB+andnon‐LGB+areindicatedwith*forp‐value<0.05,**for

p‐value<0.01,and***forp‐value<0.001.

June2021

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ISSUEBRIEF 4

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HEALTHCOVERAGE

TheACAexpandedaccesstohealthcov erageformillionsofAmericans,includingLGBTQ+individuals.Figu re1

demonstratesthesubstantialdeclineintheuninsuredrateamongLGB+individualsintheperiodafter

implementationoftheACA’scoverageexpansions, from17.4percentin2013toalowof8.3percentin2 016,

before

increasingto12.7percentin2019.Overall,theuni nsuredratedroppedbymorethanhalffrom2013to

2016,butfactoringinthereboundduringthe2017‐2019period,thisrepresentsa27percentrelativedecline

intheuninsuredratefrom2013to2019.

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Thelargestsingleyearincreasein

theLGB+uninsuredrateoccurredwhentherateincreasedfrom8.3percent

in2016to11.7percentin2017,a40.1percentincrease.Incomparison,thegeneralpopulation’suninsured

rateincreasedfrom10.4percentto10.7percentin2016‐2017.Thus,thepatternoftheincreasinguninsured

rateamongLGB+individuals

from2017‐2019issimilartonationaltrendsforothergroups,butsomewhat

morepronounced,andoccurredduringaperiodofreducedfundingforoutreach,attemptstorepealtheACA,

andotherpoliciesbytheTrumpadministrationthatreducedenrollment(describedatmorelengthina

previousASPEreport).

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Researchstudieshavealsopointedtomarriageequalityasanimportantfactorinexpandingcoverageoverthe

pastdecade,viaincreasedopportunitiesforspousalemployer‐sponsoredinsurance.

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Figure1:UninsuredRateoverTimeforLBG+Adults,2013‐2019

 

Note:AllestimatesarederivedfromtheNationalHealthInterviewSurvey(NHIS).

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June2021

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ISSUEBRIEF 5

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Table2presentsthedifferenttypesofcoverageforLGB+andnon‐LGB+individualsin2019.LGB+individuals

hadhigherratesofMedicaidorpublicinsuranceenrollment,lowerratesofMedicareenrollment,andlower

ratesofdualeligibilitycomparedtothenon‐LGB+population,whichlikelyreflectdifferencesinincomeand



ageacrossthetwogroups.TheLGB+populationhadapproximatelythesamelevelofenrollment inhealth

plansthroughtheMarketplacesasdidthenon‐LGB+population,at4.1percent.



Table2:HealthInsuranceCoverageamongAdultsbySexualOrientation,2019

 LGB+ Non‐LGB+

Insurancetype  

Private,notMarketplace 58.8%

(54.7%,62.8%)

58.4%

(57.3%,59.4%)

Private,Marketplace 4.1%

(2.8%,5.9%)

4.0%

(3.7%,4.3%)

Medicaid/public 17.2%

(14.3%,20.4%)

10.3%***

(9.7%,11.0%)

Other 3.9%

(2.6%,5.9%)

5.4%

(5.0%,5.8%)

Uninsured 12.7%

(10.2%,15.8%)

11.4%

(10.8%,12.1%)

Dual 0.5%

(0.2%,1.1%)

1.6%***

(1.4%,1.8%)

Medicare 2.8%

(2.0%,4.0%)

8.9%***

(8.5%,9.3%)

Missing 3.2% 2.9%

  

Notes:Weightedestimatesusingthe2019NHISadultfile.Resultsineachrowdonotincludeitemnon‐respondersin

thedenominatorwhencalculatingratesandpercentages.Asmallnumberofpersonswerecoveredbybothpublicand

privateplansandwereincludedinbothcategories.Numbersinparenthesesare95%confidenceintervals.Testsfor

differencesbetweenLGB+andnon‐LGB+areindicatedwith*forp‐value<0.05,**forp‐value<0.01,and***forp‐

value<0.001.



Table3presentsuninsuredratesamongdifferentLGB+subgroups,comparedtotheirnon‐LGB+counterparts.

TheBlackLGB+populationhadhigherratesofuninsurancecomparedtotheBlacknon‐LGB+population.

HispanicLGB+individualshadlowerratesofuninsurancethandidHispanicnon‐LGB+individuals.WhiteNon‐

Hispanic,AmericanIndian

andAlaskaNative,orothersingleormultipleraceLGB+individualsdidnothave

statisticallydifferentuninsuredratesthantheirnon‐LGB+counterparts.





June2021



ISSUEBRIEF 6



Table3:SubgroupAnalysisofPercentUninsuredofAdultsbySexualOrientation,2019

 LGB+ Non‐LGB+

ByAgeGroup(<65)  

18‐25 12.0%

(7.6%,18.4%)

16.2%

(14.3%,18.4%)

26‐34 22.0%

(15.7%,30.0%)

18.1%

(16.5%,19.7%)

35‐54 11.1%

(7.7%,16.1%)

14.0%

(13.0%,15.1%)

55‐64 3.1%

(1.2%,8.2%)

10.0%***

(8.9%,11.1%)

  

ByRace/Ethnicity  

Hispanic 17.7%

(11.3%,26.7%)

27.6%*

(25.5%,29.8%)

White(non‐Hispanic) 8.4%

(6.2%,11.4%)

7.5%

(6.9%,8.0%)

Black(non‐Hispanic) 24.9%

(15.3%,37.7%)

11.7%*

(9.9%,13.7%)

AsianAmerican/PacificIslander

(non‐Hispanic)

[Couldnotbecalculatedduetosmallsamplesize]

AmericanIndian/AlaskaNative(non‐

Hispanic)

41.6%

(19.7%,67.5%)

20.8%

(15.9%,26.8%)

Othersingleormultipleraces 21.2%

(6.9%,49.4%)

13.2%

(8.4%,20.1%)

  

Notes:Resultsaresurvey‐weightedestimatesusingthe2019NHISadultfile.Numbersinparenthesesare95%

confidenceintervals.TestsfordifferencesbetweenLGB+andnon‐LGB+areindicatedwith*forp‐value<0.05,**for

p‐value<0.01,and***forp‐value<0.001.



Table4describesthenetchangeinuninsuredratesbysubgroupwithintheLGB+population,for2013vs.

2019.Overall,wefindthatthelargestreductionintheuninsuredrateoccurredamongtheyoungest(18‐25)

andoldest(2019)groups,andamongWhiteNon‐HispanicLBG+individuals.However,givensmall

samplesizes

andthewideconfidenceintervalsforsomeofthesesubgroups,theseresultsshouldbeinterpretedwith

caution.





June2021



ISSUEBRIEF 7



Table4:ChangesintheUninsuredRates,2013vs.2019,forLGB+Adults–BySubgroup

 2013 2019

Overall 17.4%

(14.7%,20.4%)

12.7%

(10.2%,15.8%)

 

ByAgeGroup(<65)  

18‐25 20.0%

(13.4%,28.7%)

12.0%

(7.6%,18.5%)

26‐34 23.0%

(17.0%,30.3%)

22.0%

(15.7%,30.0%)

35‐54 17.0%

(12.8%,22.2%)

11.1%

(7.7%,16.1%)

55‐64 18.8%

(12.1%,28.2%)

3.1%

(1.2%,8.2%)

  

ByRace/Ethnicity  

Hispanic 20.7%

(13.6%,30.3%)

17.7%

(11.3%,26.7%)

White(non‐Hispanic) 15.4%

(12.3%,19.1%)

8.4%

(6.2%,11.4%)

Black(non‐Hispanic) 25.4%

(18.3%,34.2%)

24.9%

(15.3%,37.7%)

Othersingleormultipleraces 16.7%

(8.8%,29.4%)

16.0%

(7.9%,29.8%)

  

Notes:Weightedestimatesusingthe2019and2013NHISadultfiles.Resultsineachrowdonotincludeitemnon‐

respondersinthedenominatorwhencalculatingratesandpercentages.Numbersinparenthesesare95%confidence

intervals.Forthepurposesofthissetofanalyses,duetodataconstraints,“othersingleormultipleraces”includes

everyonewhoisnotHispanic,non‐HispanicWhite,andnon‐HispanicBlack.ThefirstconstraintisthatAmerican

Indian/AlaskaNativewasnotaseparatecategoryinthe2013dataandhadtobeincludedinthe“othersingleor

multipleracescategory”forbothyearsforconsistency.AnotherotherdataconstraintisthattheAsian

American/PacificIslandercategoryissosmallthatestimatesforthatgroupcouldnotbecalculatedseparately.



WhiletheNHISdoesnothaveinformationongenderidentity,non‐governmentdatasourcessuggestsimilar

benefitsoftheACAoncoverageratesamongtransgenderindividualsastheNHIStrendsforLGB+populations.

Forinstance,onesurveyreportedthattheuninsuredratefortransgenderwas14%inMedicaidexpansion

states,

asopposedto29%innon‐expansionstates,asof2020.



InadditiontotheACAimprovingratesofhealthcarecoveragefortheLGBTQ+community,theARPextends

andexpandsMarketplacesubsidies,whichwillenablemanyAmericansincludingLGBTQ+individualstoaccess

moreaffordablecoverage.ArecentASPEanalysisestimatedthat3outof5uninsuredadultsnowhaveaccess

to

azero‐premiumplanonHealthcare.gov,

and79percentofcurrentMarketplaceenrolleeshaveaccesstoa

zero‐premiumplan.

Basedonthesurveyestimatesabove,ifthatsameshare(79percent)ofLGB+enrollees

inMarketplacecoveragehaveazero‐premiumoptionundertheARP,thiswouldtotalroughly210,000

†

LGB+

Marketplaceenrolleeshavingaccesstoazero‐premiumplan.

_______________________



†

Thereareapproximately209Madultsage18oroverintheU.S.Multiplyingthisfigureby3.1%(thepercentageoftheU.S.adultLGB+

populationthatisoverage18,showninthelastrowofTable1),thenby4.1%(thepercentageoftheLGB+populationwith

Marketplacecoverage,showninthesecondrowofTable2),andthenby79%(fromthepriorASPEanalysismentioned inthetext)this

resultsinanestimateofapproximately210,000LGBTQ+Marketplaceenrolleeshavingaccesstoazero‐premiumplan.

June2021



ISSUEBRIEF 8



CHALLENGESANDDISPARITIESINACCESSTOCAREANDHEALTHOUTCOMES

IndividualsintheLGBTQ+communityfaceawiderangeofchallengesinaccessingandutilizingcarethatcan

contributetodisparitiesinhealthoutcomes.

Table5showsthatLGB+individualsintheNHISaremorelikelyreportdelayingcare,lesslikelytohaveausual

sourceofcare,andmorelikely

tobeconcernedaboutmedicalbillsthantheirnon‐LGB+counterparts.The

costofservicesisasignificantbarriertocareformanyLGB+individuals.Evenforthosewithhealthinsurance,

healthcareservicesutilizedbyLGBTQ+individualsmaybeprohibitivelyexpensiveornotcoveredatall,

particularlyfortransgenderor

othergenderminorities.TherelativelyhighpercentageoftheLGB+popula tion 

thathasdelayedcounselingandtherapyduetocostisparticularlyconcerninggiventhatindividualsinthis

populationfacehigherratesofmultiple formsofviolence,such assexualassault,interpersonalviolence,and

harassmentforwhichtheycanbenefitfrom

counseling.

SomeLGBTQ+subgroups,suchastransgender

womenofcolor,experiencedisproportionateratesofviolence,assault,andharassment.

Thesetraumatic

experiencesmaycontribu tetoobserveddisparitiesinmentalhealth,substanceusedisorder,andassociated

adversehealthoutcomesamongLGBTQ+individuals.

LGBTQ+individualsarealsoatsignificantlyhigherrisk

forsuicideandself‐harm,comparedtotheirnon‐LGBTQ+counterparts.

10,11



Table5:HealthcareAccessbySexualOrientation,2019

 LGB+ Non‐LGB+

Delayedcareduetocostin

previous12months

 

Dentalcare 26.9%

(23.6%,30.6%)

21.4%**

(20.8%,22.2%)

Counseling/therapy 18.4%

(15.4%,21.9%)

4.0%***

(3.7%,4.4%)

Prescriptions 13.2%

(10.5%,16.6%)

7.6%***

(7.2%,8.1%)

Medicalcare 15.3%

(12.8%,18.3%)

8.8%***

(8.3%,9.2%)

  

Hasusualsourceofcare 87.1%

(84.3%,89.5%)

89.6%

(89.0%,90.1%)

  

Worriedaboutbeingabletopay

forapotentialmedicalbillifgot

sickorwasinjured

53.8%

(49.7%,57.9%)

46.6%**

(45.7%,47.5%)

  

Notes:Weightedestimatesusingthe2019NHISadultfile.Thecategoriesondelayedcarewereonlyaskedof

thosewhoreportedusingthatserviceinthepastyear,anditemnon‐responsewasgenerallyunder1%forthese

questionsamongthosewhowereaskedthequestion.Resultsineachrowdonotincludeitemnon‐responders

inthedenominatorwhencalculatingratesandpercent.Numbersinparenthesesare95%confidenceintervals.

TestsfordifferencesbetweenLGB+andnon‐LGB+areindicatedwith*forp‐value<0.05,**forp‐value<0.01,

and***forp‐value<0.001.



However,LGBTQ+individualscanfaceadditionalbarrierstoaccessingcarebeyondhealthcarecosts.For

instance,LGBTQ+individ ualsmayhavedifficultyfindingLGBTQ‐friendlyproviders.

Basedonoriginalanalysisof

2019datafromtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)BehavioralHealth

June2021



ISSUEBRIEF 9



TreatmentServicesLocator, wefound thatonlyhalfofthetreatmentfacilitiesofferservicesforLGBTQ+

clients.

Lackofknowledgeofthefullrangeoflesbian,gay,bisexual,andtransgenderhealthneedscanleadto

suboptimalhealthservicesandprogramsforthispopulation.



Unfortunately,LGBTQ+individualsroutinelyexperiencemistreatmentanddiscrimination whentryingto

accesshealthcare.Accordingtoarecentsurvey,18percentofLGBTQ+individualsreportedavoidinggoingtoa

doctororseekinghealthcareoutofconcernthattheywouldfacediscriminationorbetrea tedpoorlybecause

oftheirsexualorientationor

genderidentity.

14

Thesenegativeexperiencescantranslateintopatientsfeeling

fearfulorhavelevelsofmistrustindisclosingtheirsexualorientationorgenderidentitytoprovidersand

otherwiseadvocatingfortheirownhealthcareneeds.

Researchsuggeststhatsubstantialmajoritiesof

LGBTQ+peopleagreethatitisimportantfortheirproviderstoknowabouttheirsexualorientationandgender

identity.Conversely,whenprovidersdemonstrateknowledgeof,andsensitivityabout,theircommunityand

concerns,LGBTQ+patientsaremorelikelytoestablisheffectivetherapeuticalliances.

16

Improvingthecultural

competency

‡

ofhealthsystemsandprovidersnotonlyimprovesthequalityofcarereceivedbyLGBTQ+

individuals,butwhenextendedtoracial/ethnicculturalcompetence,itmayalsoreducetheresulting

disparitiesexperiencedbyBlack,Indigenous,andpeopleofcolor.

17



POLICYOPPORTUNITIES&CONCLUSION

Inadditiontoimplementingtheprovisions oftheARP,whichmakeinsurancecoveragemoreaffordableforall

enrollees,includingLGBTQ+individuals,theDepartmentofHealthandHumanServicesrecentlyannounced

thatitwouldapplytheACA’sprohibitionofdiscriminationonthebasisofsextoincludediscriminationonthe

basisof

genderidentityandsexualorientation,consistentwiththeSupremeCourt’srulinginBostockv.

ClaytonCounty,140S.Ct.1731(2020).

Thisensuresthatcoveredhealthplans(purchasedthroughthe

Marketplaceorotherwise)cannotdenycoverageorchargehigherpremiumsonthebasisofsexualorientation

orgenderidentityandthathealthplanspurchasedthroughtheMarketplacethatofferspousalcoverageto

heterosexualcouplesalsoextendsuchcoveragetosame‐sex

couples.Thisalsoensuresthatcovered

healthcareprovidersarerequiredtoprovide medicallynecessarycaretopeopleregardlessoftheirsexual

orientationorgenderidentity,suchasensuringthattransgendermenarenotdeniedcervicalpapsmears.

LimitedcollectionandavailabilityofdatarelatedtotheLGBTQ+populationmakeresearchrelated

tothis

communitymorechallenging.Improvedandtailore dsamplingmethodologiesarerequiredtothoroughly

exploreresearchquestionsonthehealthandwell‐beingoftheLGBTQ+community.AccordingtotheNational

InstitutesofHealth(NIH)’sSexual&GenderMinorityResearchOffice(SGMRO),thisbeginswiththe

developmentofnovelmeasures

andtheevaluationofexistingmeasuresofLGBTQ+statusandexperiencesof

stigmaanddiscrimination.Inaddition,betterunderstandingthero leofgeneralizabilityinsexualandgender

minority‐focusedresearchwillbecriticalasthisfieldofresearchexpands.



InordertoimprovethequalityofhealthcarefortheLGBTQ+community,organizationsshouldstriveto:

 gatherdataonsexualorientationandgenderidentitytoexpandresearchinthisareaandbetter

understandtheneedsandexperiencesofthesepopulations;

 promotemeaningfulrelationshipsbetweenhealthcareprovidersandLGBTQ+

communitypartner

organizations;

_______________________



‡

Culturalcompetencyisdefinedastheabilityofsystemstoprovidecaretopatientswithdiversevalues,beliefsandbehaviors,

includingtailoringdeliverytomeetpatients’social,cultural,andlinguisticneeds.

June2021



ISSUEBRIEF 10



 instituteorganizationaltrainingonevidence‐basedandbestpracticesinprovidingculturallycompetent

andlinguisticallyappropriateareforthesepopulations;and

 developandimplementmoreinclusivesystemsofcarethatensureLGBTQ+andotherminority

populationsreceiveequitablecare.



June2021



ISSUEBRIEF 11



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practicalapproaches.NewYork:TheCommonwealthFund.

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1972.OfficeoftheFederalRegister,NationalArchivesandRecordsAdministration,24May2021,

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05‐25/2021‐10477

NationalInstitutesofHealth."Strategicplantoadvanceresearchonthehealthandwell‐beingofsexual&gender

minorities,FiscalYears2021–2025."USGovernmentPrintingOffice(2020).

June2021



ISSUEBRIEF 12



U.S.DEPARTMENTOFHEALTHANDHUMANSERVICES



OfficeoftheAssistantSecretaryforPlanningandEvaluation



200IndependenceAvenueSW,Mailstop447D

Washington,D.C.20201



FormoreASPEbriefsandotherpublications,visit:

aspe.hhs.gov/reports



ABOUTTHEAUTHORS

ArielleBosworthisanEconomistintheOfficeofHealthPolicyin

theOfficeoftheAssistantSecretaryforPlanningandEvaluation.

GinaTurriniisaSocialScienceAnalystintheOfficeofHealth

PolicyintheOfficeoftheAssistantSecretaryforPlanningand

Evaluation.

SaradaPyda

isanEconomistintheOfficeofHealthPolicyinthe

OfficeoftheAssistantSecretaryforPlanningandEvaluation.

KieaunaStricklandisanInternintheOfficeofHealthPolicyin

theOfficeoftheAssistantSecretaryforPlanningandEvaluation.

AndreChappelistheDirectoroftheDivision

ofPublicHealth

ServicesintheOfficeoftheAssistantSecretaryforPlanningand

Evaluation.

NancyDeLewistheAssociateDeputyAssistantSecretaryfor

HealthPolicyintheOfficeoftheAssistantSecretaryforPlanning

andEvaluation.

BenjaminD.SommersistheDeputyAssistantSecretaryforthe

OfficeofHealth

PolicyintheOfficeoftheAssistantSecretaryfor

PlanningandEvaluation.



SUGGESTEDCITATION

Bosworth,A.,Turrini,G.,Pyda,S.,Strickland,K.,Chappel,A.,De

Lew,N.,andSommers,B.HealthInsuranceCoverageandAccess

toCareforLGBTQ+Individuals(IssueBriefNo.HP‐2021‐14).

OfficeoftheAssistant

SecretaryforPlanningandEvaluation,U.S.

DepartmentofHealthandHumanServices.June2021.



Allmaterialappearinginthisreportisinthepublicdomainand

maybereproducedorcopiedwithoutpermission;citationasto

source,however,isappreciated.



DISCLOSURE

Thiscommunicationwasprinted,published,or

producedand

disseminatedatU.S.taxpayerexpense.



HP‐20XX‐XX

June2021



ISSUEBRIEF 13



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