Impact of Health Care Reform on the LGBT Community

The Center for American Progress has released an issue brief detailing how health care reform could help LGBT people and families in the United States. The brief’s author, Josh Rosenthal, focuses on a few key principles for policymakers to consider when reforming our current health care system.

First, he argues that medical professionals and policymakers need to understand the health disparities that affect LGBT people. This could be done by collecting information about respondents’ sexual orientation in federal health surveys. The largest and most widely referenced federal health survey, the National Health Interview Survey, does not ask about LGBT identities, making it difficult for anyone to know exactly what disparities may be present in the LGBT community.

The employer-sponsored health insurance set-up is also a barrier to many LGBT people receiving quality health care. Many employers do not permit LGBT employees to include their same-sex partners under their health insurance coverage, and private health insurance plans often don’t cover services vital for LGBT people. Rosenthal writes:

Since 63 percent of Americans are covered through employer-sponsored insurance, a large part of the disparity can be attributed to differences in employment patterns, due to both discrimination and individual employment choices. Transgender people are even less likely to have employer-sponsored health insurance, as they face significant employment discrimination and often lack any formal employment.

Many LGBT people are forced into the individual insurance market since they do not have an employer willing to provide insurance coverage. This market is fundamentally broken, charging high premiums for limited coverage. What’s more, LGBT individuals are more likely to have HIV/AIDS or several cancers, such as breast, cervical, and anal cancers. These diseases are classified as “pre-existing conditions” by individual insurance providers, leading them to either completely exclude people or charge even higher rates.

In the brief, Rosenthal focuses particularly on the needs of transgender individuals and the discrimination they face in accessing health care:

Transgender individuals with access to health insurance can rarely find coverage that fully meets their health care needs. Most insurance plans, both private and public, do not cover the costs associated with transitioning, or moving from one gender to another. This leads many transgender people—especially low-income people—to seek out ways to transition outside of a medical context.

Some insurance plans interpret their regulations on transition costs very broadly. They refuse any medical procedure where hormone use or past surgeries are relevant, even procedures as generic as allergy tests. There is also evidence that insurance companies use a history of transition treatments as a reason to deny coverage. The Transgender Law Center has even found examples where insurance companies have denied coverage for a broken arm and flu treatment to transgender individuals, claiming the treatment was related to transition.

Rosenthal also writes that cultural competency in medical professionals will go a long way toward addressing the particular health care concerns of the LGBT community. Cultural competency is “a set of behaviors, attitudes, and policies that allow providers to work effectively in cross-cultural situations.” He examines the effect cultural competency would have on different segments of the LGBT population:

An essential prerequisite for cultural competency is an understanding of a social group’s specific health disparities and medical needs. Lesbian and bisexual women, for example often have a number of risk factors for breast cancer, including often not having given birth. Yet many studies have shown that lesbian and bisexual women are less likely to receive regular gynecological care, including mammograms or pap smears, or examine themselves for breast cancer.

Transgender people also have very specific health needs. They may require medical treatment related to both their birth-assigned gender and their current gender. For example, a transgender woman may be at risk for both prostate cancer and breast cancer. Providers should also be aware of the medical effects of gender transition.

This medical knowledge is important, but not sufficient. A culturally competent provider adds an understanding of their patients’ backgrounds and is able to create a welcoming environment and recognize the effects of his or her own biases. A provider can signal her openness to LGB patients, for example, by asking non-gender specific questions on forms and in interviews, such as “Do you have a significant other?” Culturally competent treatment helps ensure honest communication between providers and patients, which can improve health outcomes.

Unfortunately, many LGBT people do not have access to a culturally competent health provider. For example, the reproductive orientation of much gynecological care, which focuses on providing birth control to heterosexual women, discourages many lesbian and bisexual women from seeking out care.

Transgender individuals find an even more hostile medical environment. There is already a risk that insurance could deny coverage for a medical interaction. And many health care providers have no training in how to treat transgender people with respect. Many transgender people report in qualitative studies that they avoid medical care or lie to providers in order to avoid hate-filled or ignorant comments.

The entire brief is worth a read, and examines other topics such as ensuring the privacy of LGBT patients, costs of adding transgender-inclusive health options to employer policies, and more. We hope that policymakers are mindful of the particular needs of the LGBT community when debating and enacting health care reform.


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The Women's Law Project creates a more just and equitable society by advancing the rights and status of all women throughout their lives. To this end, we engage in high-impact litigation, advocacy, and education.
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