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Why Repealing the Affordable Care Act Is Bad Medicine for LGBT Communities

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This material was published by the Center for American Progress. Kellan Baker and Laura E. Durso contributed to this report.

The Affordable Care Act, or ACA, has helped more than 20 million people get new health insurance coverage. Millions more are benefitting from the ACA’s bans on coverage denials because of pre-existing conditions, unaffordable prices for bare-bones coverage, and discrimination in coverage and health care.

Lesbian, gay, bisexual, and transgender, or LGBT, communities have often experienced high rates of uninsurance and barriers to coverage and care, such as discrimination on the basis of gender identity and sexual orientation. A new study by the Center for American Progress, or CAP, finds that 15 percent of LGBT Americans across all income ranges are uninsured in 2017, compared to 7 percent of non-LGBT Americans.

The ACA is closing this gap for those who most need financial help to afford coverage. In 2013, before the ACA’s coverage reforms came into effect, 1 in 3 LGBT people making less than $45,000 per year (34 percent) were uninsured. Just one year later, in 2014, uninsurance for this group had dropped by one-quarter to 1 in 4 (26 percent), and by 2017, CAP’s study finds that it was around 1 in 5 (22 percent). Conservative proposals to repeal and replace the ACA — such as the American Health Care Act, or AHCA — would undo these gains and hurt LGBT people, their families, and their neighbors. The path to a stronger, healthier America for all lies not in depriving millions of Americans of the benefits of coverage but in protecting and expanding on the gains of the ACA.

Study methods

To conduct this study, CAP surveyed 1,864 individuals about their experiences with health insurance and health care. Among the respondents, 857 identified as lesbian, gay, bisexual, and/or transgender, while 1,007 identified as heterosexual and cisgender/nontransgender. Respondents came from all income ranges and are diverse across factors such as race, ethnicity, education, geography, disability status, and age. The survey was fielded online in English in January 2017 to coincide with the fourth open enrollment period through the health insurance marketplaces and the beginning of the first full year of federal rules that specifically protect LGBT people from discrimination in health insurance coverage and health care. The data are nationally representative and weighted according to U.S. population characteristics. All reported findings are statistically significant unless otherwise indicated.

Respondent characteristics

Overall, LGBT people are more than twice as likely to be uninsured as non-LGBT people: 15 percent of LGBT respondents are uninsured, compared to 7 percent of non-LGBT respondents. This finding aligns with recent reports that the overall uninsurance rate for all Americans is 8.6 percent. Uninsurance is highest among transgender individuals: 25 percent of transgender respondents are uninsured, compared to 8 percent of cisgender respondents. Among sexual minority respondents, bisexual individuals have a higher level of uninsurance (19 percent) than gay men (6 percent) and lesbians (4 percent). Individuals who identify as queer and asexual also have high rates of uninsurance (17 percent and 50 percent, respectively), though small sample sizes did not allow statistical testing of these coverage gaps.

Among LGBT respondents, people living in the South are significantly more likely than people living in the Northeast to not have coverage (21 percent versus 9 percent uninsured, respectively). This difference is much smaller and not statistically significant for non-LGBT respondents in these regions (11 percent versus 8 percent), suggesting that the hostile legal and social climates experienced by LGBT communities in the South—in addition to the lack of Medicaid expansion in this region—may be contributing to higher rates of uninsurance for LGBT people.

Among all respondents, African Americans are significantly more likely than white Americans to be uninsured (17 percent versus 5 percent). Latinx individuals and individuals who reported two or more racial identities also have higher rates of uninsurance (14 percent and 10 percent), though these differences are not statistically significant. Among LGBT respondents, there are no significant differences in coverage by race or ethnicity: 14 percent of white respondents, 14 percent of African Americans, 33 percent of Latinx individuals, and 3 percent of individuals who reported two or more racial identities are uninsured.

Impact of the American Health Care Act on LGBT communities

Features of the ACA, such as income-based tax credits, to help make coverage more affordable and the expansion of Medicaid provide significant benefits for lower-income communities, including LGBT people who are struggling economically. By contrast, the American Health Care Act — the new health care proposal that is up for a vote in the House of Representatives on the anniversary of the ACA’s passage — would undermine these benefits by stripping coverage from 24 million people and raising costs for low-income people, seniors, and other vulnerable Americans.

Overall, LGBT people—especially transgender people, LGBT people of color, and LGBT parents—are significantly more likely than non-LGBT people to live in poverty. Among LGBT respondents in the CAP survey, 34 percent live in households earning less than $35,000 per year. Many more are in precarious financial circumstances: In general, LGBT respondents are significantly less likely than non-LGBT respondents to be confident of being able to afford regular medical costs, such as doctor visits and prescription medications (81 percent versus 90 percent); less likely to be confident of being able to afford major medical costs, such as hospitalization (72 percent versus 82 percent); and more likely to have medical bills that they cannot pay (19 percent versus 12 percent).

Insurance provides a critical shield against these concerns: Regardless of income, insured LGBT respondents are more than twice as likely to be confident they can afford regular medical costs (90 percent of the insured versus 38 percent of the uninsured) and more than three times as likely to be confident they can afford major medical costs (82 percent of the insured versus 24 percent of the uninsured).

The broadening of affordable insurance options under the ACA through both traditional and expansion Medicaid and the health insurance marketplaces is essential to the health and financial well-being of LGBT Americans. For instance, among LGBT respondents who explored their coverage options in the past year, 36 percent found they are eligible for Medicaid, and three-quarters of those who are eligible subsequently enrolled. Among all LGBT respondents, 18 percent have Medicaid coverage, and among those with incomes less than 250 percent of the federal poverty level, or FPL, the proportion rises to 40 percent.* By comparison, Medicaid covers 8 percent of all non-LGBT respondents and 22 percent of non-LGBT respondents with incomes under 250 percent of the FPL. Using the most recent estimate of the size of the LGBT population, approximately 1.8 million LGBT adults have Medicaid coverage.

Of LGBT respondents who sought coverage through a health insurance marketplace in the past year and were not eligible for Medicaid, more than half (51 percent) learned they are eligible for advance premium tax credits that make their plans more affordable. Marketplace coverage options are particularly important for same-sex couples in light of continuing discrimination by employers on the basis of sexual orientation: Although lesbian, gay, and bisexual, or LGB, and heterosexual respondents are equally likely to have coverage through their own employer (38 percent and 39 percent, respectively), LGB individuals are less than half as likely as heterosexual individuals to have access to coverage through a spouse or partner’s employer (7 percent versus 18 percent).

The future of America’s health

A great deal is at stake for LGBT people—and all Americans—in the current debate about the future of the Affordable Care Act. The ACA’s reforms have helped expand the availability of health insurance coverage and are strengthening the links between affordable coverage and high-quality care. By contrast, the AHCA’s proposal to slash Medicaid funding and cut financial assistance that helps lower-income people afford coverage has serious consequences for millions of Americans, including LGBT people and their families. The bill would prevent the uninsured from gaining coverage and cause many of those who have gained coverage under the ACA to lose it. To truly improve the health of all Americans, the nation should move forward with continuing to build on the foundation laid by the ACA rather than allowing the clock to be rolled back to the era of high costs, poor quality, and rampant uninsurance.

Kellan Baker is a Senior Fellow with the LGBT Research and Communications Project at the Center for American Progress. Laura E. Durso is the Vice President of the Center’s LGBT Research and Communications Project.

The Center for American Progress is a progressive think tank dedicated to improving the lives of Americans through ideas and action.

* Note: Precise income data to calculate the income-to-poverty ratio were not available through the current survey. In the survey data, respondents’ annual household income is given in ranges—with smaller increments of $2,500 to $5,000 for lower-income respondents and larger increments of $25,000 to $50,000 for high-income respondents. To assess income relative to the FPL, the authors assigned each respondent income at the midpoint of their income range—for example, those in the range of $5,000 to $7,499 are assigned income of $6,250—and then divided midpoint income by the poverty guideline corresponding to the respondent’s household size.

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Study: Only 4% Gay & Bi Men Use PrEP

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Only 4 percent of gay and bisexual men in the United States reported using pre-exposure prophylaxis, or PrEP; this according to a new study recently published in PLOS ONE. The study also revealed that bisexual and non-urban men were less likely than gay men to use PrEP; while visiting an LGBT clinic and searching for information online on LGBT sources were associated with PrEP use.

PrEP is a pill taken daily that reduces the likelihood of being infected with HIV by over 99 percent and is recommended by the Centers for Disease Control and Prevention (CDC) for those at high risk of HIV/AIDS. Currently, Truvada, manufactured by Gilead, is the only form of PrEP approved by the Food & Drug Administration.

The study used data from the Generations Study using a national probability sample of 470 male participants from three age cohorts: 18-25, 34-41, and 52-59. Researchers examined HIV testing and use, familiarity, and attitudes toward PrEP among HIV-negative gay and bisexual men in the U.S. Participants completed the survey between March, 2016 and March, 2017.

ACCESS, FAMILIARITY & ATTITUDES

“The extremely low rate of PrEP use, while not surprising given barriers to access in various parts of the country, is disappointing,” said Professor Phillip Hammack of the University of California Santa Cruz’s Department of Psychology. Since it was approved for PrEP six years ago, the wholesale price for Truvada in the U.S. has risen 45 percent, with the list price for a 30-day supply close to $2,000.

Despite low usage, a majority of particpants — 60 percent — reported that they were familiar with PrEP, with the middle cohort, ages 34-41, reporting the highest familiarity at 79 percent. Attitudes toward PrEP were also positive among most men — 68 percent of all participants, with the younger cohort, ages 18-25, at 76 percent.

HIV TESTING

The study also showed that most men did not meet the CDC recommndations for annual HIV testing with more than 25 percent of men in the younger cohort, ages 18-25, and 8 percent of men over 25 never having been tested for HIV.

“I worry especially about younger men who didn’t grow up with the concerns of HIV that men of older generations did,” said Hammack. “The low rate of HIV testing probably reflects a degree of complacency and cultural amnesia about AIDS.”

“Our findings suggest that health education efforts are not adequately reaching sizable groups of men at risk for HIV infection,” says principal investigator Ilan H. Meyer of the Williams Institute at the UCLA School of Law. “It is alarming that high-risk populations of men who are sexually active with same-sex partners are not being tested or taking advantage of treatment advances to prevent the spread of HIV.”

The study suggests that “efforts to educate gay and bisexual men about HIV risk and prevention need to be reinvigorated and expanded to include non-gay-identified and non-urban men”.

The study was supported by the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health.

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Planned Parenthood, Black AIDS Institute Partner to Expand Comprehensive HIV Prevention Services Nationwide

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Planned Parenthood announced a multi-phase pilot program to build and expand its comprehensive HIV prevention and education efforts. Gilead Sciences, Inc, a research-based biopharmaceutical company, awarded the $900,000 grant to support and expand efforts of HIV prevention and education, including the integration of Pre-Exposure Prophylaxis (PrEP) awareness, at Planned Parenthood affiliate health centers across the country over the next 18 months. It is the first significant corporate grant of its kind awarded to Planned Parenthood, and will focus critical prevention efforts in communities hardest hit by the epidemic.

The grant work will be carried out in partnership with The Black AIDS Institute, the only national HIV/AIDS think tank in the United States focused exclusively on Black people.

“Planned Parenthood is thrilled to be launching this incredibly exciting project. Although this country has made progress toward greater health care equity, disparities in HIV rates remain a serious issue for too many people and too many communities,” said Dr. Raegan McDonald-Mosley, chief medical officer at Planned Parenthood Federation of America. “Rates of new HIV cases, along with barriers to treatment and health care access, continue to more greatly impact marginalized communities. With this grant, Planned Parenthood can implement life-saving awareness and care not otherwise funded at this scale. It furthers our mission to provide all people, especially those already facing barriers to accessing quality health care, with comprehensive and cutting-edge HIV prevention methods, including PrEP”.

PrEP is the medical practice of prescribing antiretroviral medication to prevent against HIV infection.

“The Black AIDS Institute is proud to partner with Planned Parenthood to expand comprehensive HIV prevention services to Black Women”, Phill Wilson, President and CEO of the Black AIDS Institute. “Given the disproportionate impact HIV is having on Black women and the new tools we have at our disposal, this is the right thing to do at the right time.”

The majority of the grant will directly support the efforts of Planned Parenthood affiliates to develop training and resources aimed at delivering a comprehensive program of HIV prevention, including PrEP and other methods, in health centers across the country. It will also go toward the creation of patient education materials to reach populations most at-risk for HIV, as well as capacity-building sustainable learning modules across affiliates.

“Scientific innovation has greatly improved our ability to address the HIV epidemic,” said Gregg Alton, Executive Vice President, Corporate and Medical Affairs for Gilead Sciences, Inc. “Alongside that innovation, diverse programs and partnerships are helping to ensure we can reach those most in need of treatment and prevention options. Prevention strategies, including PrEP and other methods, can have a meaningful impact on public health, offering an unparalleled opportunity to avert new infections and reduce long term costs to the healthcare system.”

Planned Parenthood provides high-quality, compassionate care in health centers across the country, including nearly 700,000 HIV tests each year. Planned Parenthood health centers are uniquely positioned to deliver HIV prevention services and education to disproportionately impacted communities, including Black women, Latinas, transgender people, young adults of all backgrounds, and men who have sex with men, especially people of color.

Dr. McDonald-Mosley added, “Training and resourcing more medical providers to provide HIV and PrEP education, with a particular focus on prevention in underserved communities, is a job for which Planned Parenthood is uniquely suited. For over 100 years, we’ve been fighting to ensure that people — no matter where they live — can access accurate, nonjudgmental preventive care and education so they can keep themselves and their families healthy.”

Despite the life-saving advances in highly active antiretroviral therapy (HAART) for treatment and prevention, HIV remains an urgent public health crisis, especially for certain marginalized communities who face barriers to affordable, quality health care. According to a 2014 Centers for Disease Control and Prevention (CDC) surveillance report, women of color, particularly Black women, are disproportionately affected by HIV, accounting for the majority of the HIV infections, women living with HIV, and HIV-related deaths among women in the U.S.

“Over 40% of people living with HIV in the U.S are Black. Nearly 50% of new HIV infections in this country are Black. and 1 in 32 black women, 1 in 16 black men, and 1 and 2 Black Gay men will be diagnosed with HIV infection in their lifetime. Yet 85% of current PrEP users are white men. What’s wrong with this picture”, says Leisha McKinley Beach, technical assistance consultant, Black AIDS Institute.

While awareness of antiretroviral medication as pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) has risen significantly, women at risk for HIV still face several challenges in getting the services and information they need, including structural and cultural barriers such as poverty, HIV stigma, and a relative lack of access to healthcare professionals trained to offer comprehensive HIV prevention, including PrEP and other methods.

As part of our mission to help people live healthy lives, Planned Parenthood works every day in communities across the country and with partners around the world so that everyone — no matter who they are or where they live — can access accurate, high-quality, compassionate sexual and reproductive health care.

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RBJ Health Center Named Leader in LGBT Healthcare Equality

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The Human Rights Campaign (HRC) Foundation, the educational arm of the country’s largest lesbian, gay, bisexual and transgender (LGBT) civil rights organization, has named Austin/Travis County Health and Human Service’s Sexually Transmitted Disease (STD) Clinic at the Rebekah Baines Johnson (RBJ) Health Center as a “Leader in LGBT Healthcare Equality”. The findings were part of HRC Foundation’s Healthcare Equality Index 2016, a unique annual survey that encourages equal care for LGBT Americans by evaluating inclusive policies and practices related to LGBT patients, visitors and employees.

The RBJ Health Center earned top marks in meeting non-discrimination and training criteria that demonstrate its commitment to equitable, inclusive care for LGBT patients, and their families, who can face significant challenges in securing the quality health care and respect they deserve. “This recognition acknowledges our commitment to create an inclusive and welcoming environment for every patient, customer, client and employee,” said Shannon Jones, Director-Austin/Travis County Health and Human Services.

The RBJ Health Center is one of a select group of 496 healthcare facilities nationwide to be named Leaders in LGBT Healthcare Equality. Facilities awarded this title meet key criteria, including patient and employee non-discrimination policies that specifically mention sexual orientation and gender identity, a guarantee of equal visitation for same-sex partners and parents and LGBT health education for key staff members.

The Healthcare Equality Index 2016 offers healthcare facilities unique and powerful resources designed to help provide equal care to a long-overlooked group of patients, as well as assistance in complying with regulatory requirements and access to high-quality staff training.

For more information about the Healthcare Equality Index 2016, or to download a free copy of the report, visit www.hrc.org/hei.

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