COVID Is Devastating LGBTQ People’s Ability to Access Health Care
The first doses of a COVID-19 vaccine are now being handed out across the country, but for LGBTQ people, it’s going to take more than just medication to recover from the ravages of the coronavirus pandemic, according to a new report.
An analysis from the Movement Advancement Project (MAP), a think tank, released on Wednesday, found that since the pandemic began, LGBTQ people have been hit hard in just about every imaginable way. Compared to non-LGBTQ people, they’re more likely to have lost their jobs. They’re more likely to say that they couldn’t access health care. And they’re more likely to say that they haven’t had enough to eat over the last few months.
All of these differences have their roots in discrimination, and are particularly stark for LGBTQ people of color, according to the organization.
“The pandemic has disrupted life for all of us. Yet, some communities have borne the brunt: Black and Latinx people, low-income people, and, as this new data show, LGBTQ people,” Ineke Mushovic, MAP’s executive director, said in a statement alongside the release of the report, which uses data from polls conducted by National Public Radio, the Robert Wood Johnson Foundation, and the Harvard T.H. Chan School of Public Health over the summer.
The MAP analysis draws a line between the dire circumstances facing LGBTQ people in 2020, and the historical disparities that have kept them from succeeding at the same rates as their straight, cisgender peers. A 2018 survey from the Center for American Progress found that 8 percent of lesbian, gay, bisexual, and queer adults said they’d been turned away from a health care provider due to their sexual orientation. Nearly 30 percent of transgender adults said they’d been turned away due to their gender identity.
“Decades of discrimination on the job, in health care, and beyond, combined with uneven legal protections around the country make LGBTQ people more vulnerable to pandemic-related instability and insecurity, with an even more devastating impact on LGBTQ people of color,” Mushovic wrote.
Now, in the middle of the worst public health crisis in a century, the longstanding gap between people who are LGBTQ and those who are not is getting worse. The report found that 13 percent of LGBTQ people have lost health insurance since the start of the pandemic. That’s more than twice the rate of insurance loss among non-LGBTQ people, just 6 percent of whom say they’ve lost their insurance.
More than a quarter of LGBTQ households say they’ve struggled to afford medical care during the pandemic, twice the rate of non-LGBTQ households. More than 25 percent of LGBTQ households have been totally unable to get needed health care, and instead had to deal with what the report calls a “negative health consequence.” Just 10 percent of non-LGBTQ households said they had the same problem.
These disparities are even worse among different LGBTQ groups, and particularly people of color. More than half of Black LGBTQ people said that they, or someone in their household, hadn’t been able to get health care or had to delay it since the dawn of the outbreak.
In total, 66 percent of LGTBQ households said that they were facing “serious financial problems,” such as having used up the bulk of their savings, being unable to afford medical care, and struggling to pay off bills or loans. These problems are a particularly deep concern among LGBTQ households of color: Around 70 of Latinx LGBTQ respondents and almost 95 percent among Black LGBTQ respondents said that someone in their household had dealt with a serious financial problem.
The social isolation wrought by the pandemic has also wrecked LGBTQ people’s mental health at disproportionate rates. Around 23 percent of non-LGBTQ people said that they or someone in their house had a “serious problem coping with social and physical isolation,” per the report, compared to 44 percent of LGBTQ people who said the same.
“It’s clear that the COVID-19 has amplified and exacerbated disparities that existed before the pandemic,” Logan Casey, one of the authors of the report, said in a statement. “LGBTQ people were more likely to struggle with economic stability and have challenges with access to health care prior to COVID, and that’s even more true now.”
LGBTQ people cannot afford to reverse the progress made under the ACA
The ACA includes three critical components that have resulted in significant health care gains for LGBTQ people:
- The expansion of Medicaid and introduction of tax credits for private plans through the marketplaces
- Protections for people with preexisting conditions
- Nondiscrimination protections on the basis of sexual orientation and gender identity
These provisions are essential to ensuring greater access to affordable health insurance for LGBTQ people, who endure disparate negative health outcomes linked to stigma and discrimination that adversely affect their physical, psychological, and financial well-being.
Increased coverage and affordability
The ACA has been instrumental in making health insurance more affordable by expanding low-income households’ eligibility for no- or low-cost public health insurance coverage through Medicaid and by directly subsidizing private coverage purchased by low- and middle-income individuals through the health insurance marketplaces. The high prevalence of poverty among LGBTQ communities—particularly transgender people and LGBTQ people of color due to transphobia and systemic racism—make both pathways to coverage essential to support the health and well-being of LGBTQ people.
In 2013, before the ACA went into effect, 34 percent of LGBTQ individuals making less than $45,000 a year were uninsured. However, this number has dropped steadily each year in the wake of the ACA’s coverage expansions, decreasing to 26 percent in 2014, 22 percent in 2017, and, based on nationally representative survey data collected by CAP, 16 percent as of June 2020—indicating that the rate of uninsured LGBTQ people making less than $45,000 per year has halved since the ACA went into effect.
These significant improvements can largely be attributed to an increase in the number of LGBTQ people who access coverage through Medicaid or the marketplaces. As of this year, 18 percent of LGBTQ people have insurance through Medicaid, with 28 percent reporting that in the past month they, their partner, or their child had received some type of help from Medicaid. An additional 8 percent have insurance purchased through HealthCare.gov or a state marketplace.
The positive impact of Medicaid expansion is clear when comparing insurance rates among those in states that have adopted the expansion as of January 2020 with those in states that have failed to do so. According to CAP’s original survey conducted in June 2020, in states that expanded Medicaid, just 8 percent of LGBTQ adults are uninsured and 20 percent have coverage through Medicaid.** In states that have not expanded Medicaid, the rate of LGBTQ adults who are uninsured is 20 percent, with just 13 percent of respondents being covered through Medicaid. Impacts are most prominent for LGBTQ adults making less than $45,000 a year. In states with the expansion, 11 percent of these individuals are uninsured and 38 percent have Medicaid coverage—in contrast to states without the expansion, where 28 percent are uninsured and just 23 percent have Medicaid coverage. Based on these findings, it is apparent that states that adopted expansion are providing low-income LGBTQ people with better access to affordable insurance, which can make a meaningful difference to their health and well-being. Repeal of the ACA would end the law’s Medicaid expansion and financial assistance for private coverage through the marketplaces. Based on its survey data, CAP estimates that nearly 2 million LGBTQ people are covered through Medicaid and nearly 900,000 LGBTQ people are covered through the health insurance marketplaces.
Even with higher rates of coverage compared with before the ACA, LGBTQ people face immense difficulties accessing affordable health care. 29% reported postponing or not seeking out necessary medical care when sick or injured because of the cost, while 24% reported postponing or not receiving preventative screenings due to cost.
Yet the ACA lawsuit threatens to undo years of progress and push millions of LGBTQ people off of their insurance through losing access or prohibitively high costs, all without a Trump administration strategy to provide alternative options, creating significant barriers to quality, affordable health care.
Coverage of preexisting conditions
The ACA also prohibits discrimination based on preexisting conditions, meaning that insurers in the individual market cannot charge higher premiums, deny coverage, or limit benefits for preexisting health conditions such as asthma, diabetes, heart disease, cancer, and HIV. The ACA’s protections have benefited many Americans who previously faced obstacles to comprehensive health insurance because of their medical history. Indeed, as of 2017, 51 percent of U.S. adults and an estimated 65 percent of LGBTQ adults had a preexisting condition. Nationally representative data from CAP reveal that, in 2020, only 6 percent of LGBTQ people reported having trouble attaining insurance coverage due to a preexisting condition—mainly thanks to the ACA.
Eliminating these protections would lead to millions of Americans with preexisting conditions—including many LGBTQ individuals with disabilities and chronic health conditions—being denied coverage and facing substantial increases in out-of-pocket costs if they ever had to buy insurance on their own. Consequences would be especially grave for the more than 7.5 million people in the United States diagnosed with COVID-19, which would likely be considered a preexisting condition if the ACA were repealed. This would deeply impact communities of color, whose health and economic stability have been disproportionately affected by the pandemic due to intergenerational systemic racism and social determinants of health, as well as LGBTQ people more broadly, who are at increased risk of severe effects from COVID-19.
The ACA established and implemented broad-based nondiscrimination protections for LGBTQ people. This includes regulations for Section 1557 of the ACA—the law’s primary civil rights provision—which prohibits discrimination based on sexual orientation and gender identity in the U.S. Department of Health and Human Services marketplace plans and any health plans offering the ACA’s essential health benefits. Moreover, Section 1557 also protects LGBTQ people by banning discrimination based on sex and sex stereotypes in any health program receiving federal funds, including Medicaid, Medicare, and marketplace providers.
Despite attempts by the Trump administration to rescind these Section 1557 protections, courts have affirmed that the statute prohibits gender identity discrimination; and the recent landmark decision in Bostock v. Clayton County provides clear guidance indicating that sexual orientation and gender identity discrimination is more broadly prohibited.
These protections are critical for LGBTQ people, who, according to the latest nationally representative data from CAP, often postpone or avoid medical care due to experiences of discrimination. In fact, among LGBTQ people who have experienced discrimination in the past year, 36 percent avoided doctor’s offices out of fear of experiencing further discrimination by a health provider.
Absent the robust discrimination protections established by the ACA, all members of the LGBTQ community would lose the opportunity for legal recourse when encountering harmful discriminatory experiences, with consequences being particularly grave for transgender people. Although the ACA made it illegal to consider a prior diagnosis of gender dysphoria or gender identity disorder to be a preexisting condition and prohibited insurers from outright excluding or placing discriminatory restrictions on transition-related care, transgender individuals continue to face unique discriminatory barriers to accessing health insurance.
Looking ahead, a range of outcomes for the case are possible, with the most detrimental and far-reaching ramifications for LGBTQ people occurring if the Supreme Court overturns the ACA—as the U.S. Department of Justice and Republican attorneys general argue. LGBTQ people who benefited from the ACA’s policies to increase affordability, cover preexisting conditions, and ensure nondiscrimination protections cannot afford to reverse the substantial progress made under the law, particularly as a pandemic surges across the nation.
The gains made by LGBTQ people under the ACA now rest in the hands of the Supreme Court. This is a dangerous prospect given that President Trump’s nominee boasts a strong public record of opposing the ACA, access to reproductive health, and LGBTQ rights, including her defense of dissenters in the Supreme Court’s marriage equality ruling and skepticism about extending Title IX protections to transgender students. Rather than arguing for the repeal of the ACA and rushing through a Supreme Court nomination, the Trump administration should be focused on taking action to bolster the health and financial stability of Americans living through an unprecedented crisis.