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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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Studies: Transgender Hormone Therapy Less Risky Than Birth Control Pills

New research published in Men’s Health Issue of AACC’s Clinical Chemistry journal find transgender hormone therapy Is less risky than birth control pills

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Novel studies published in the Men’s Health Issue of American Association for Clinical Chemistry‘s journal Clinical Chemistry suggest that hormone therapy for transgender people increases the risk of blood clots less than birth control pills and does not increase the risk of cardiovascular disease at all. These preliminary results could help more transgender individuals to access essential hormone therapy by increasing physician comfort with prescribing it.

Obstacles to Therapy

All major medical associations agree that transgender individuals need to be able to express their gender in ways with which they feel comfortable and that this is the most effective treatment for psychological distress caused by incongruence between sex assigned at birth and gender. For many transgender individuals, expressing their gender involves physically changing their body through medical steps such as taking hormone therapy. However, transgender patients often experience difficulty getting hormone therapy prescriptions, to the point that 1 in 4 transgender women have to resort to illegally obtaining cross-sex hormones. Part of this is because existing research on transgender hormone therapy is limited and conflicting, which has led to some physicians denying patients this treatment out of concern that it could significantly increase the risk of health problems such as blood clots and cardiovascular disease.

First Study

A team of researchers led by Dina N. Greene, PhD, of the University of Washington in Seattle has now estimated that in transgender women prescribed estrogen, blood clots only occur at a rate of 2.3 per 1,000 person-years. While this is higher than the estimated incidence rate of blood clots in the general population (1.0-1.8 per 1,000 person-years), it is less than the estimated rate in premenopausal women taking oral contraceptives (3.5 per 1,000 person-years), which means that it is an acceptable level of risk. In order to determine this, Greene’s team performed a systematic review of all studies that have included the incidence rate of blood clots in transgender women receiving estrogen therapy, identifying 12 that were most relevant. The researchers then used meta-analysis to combine the results of these 12 studies and calculate a risk estimate that is based on all available evidence to date.  

“Documenting the risks associated with hormone treatment may allow for prescribers to feel more comfortable with prescribing practices, allowing for better overall management of transgender people,” said Greene. “Our data support the risk of thrombotic events in transgender women taking estrogen therapy being roughly comparable to the risk of thrombotic risks associated with oral contraceptives in premenopausal women. Given the widespread use of oral contraception, this level of risk appears to be broadly accepted.”

Second Study

In a second study, a team of researchers led by Guy G.R. T’Sjoen, MD, PhD, also conducted a systematic review of all studies that have measured risk factors for cardiovascular disease in transgender people taking hormone therapy. The researchers identified 77 relevant studies in this area and found that the majority of them report no increase in cardiovascular disease in either transgender men or women after 10 years of hormone therapy. The studies that did indicate a higher cardiovascular disease risk for transgender women in particular mainly involved patients using ethinyl estradiol, a now obsolete estrogen agent, and are therefore no longer valid.

T’Sjoen’s team does state that their results are not conclusive due to the small sample sizes and relatively short duration of the studies in this area (and Greene’s team included a similar caveat for their work). However, it is important to look at Greene and T’Sjoen’s studies in the context of transgender research as a whole. The field only began to receive National Institutes of Health funding in 2017 and is also lagging due to the fact that transgender patients often aren’t identified in medical databases that provide data for research. In light of this, these studies are significant not only because they suggest that transgender hormone therapy is safe, but also because they underscore the need for longer-term, large scale studies involving this underserved population.

Source: Press release

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Austin

Kind Clinic Launches Telehealth Service

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The Kind Clinic

Patients at Texas Health Action‘s Kind Clinic won’t have to worry about taking time off from work or figuring out how to get to the clinic. The Kind Clinic, which provides sexual health services including PrEP and PEP access, STI testing and treatment, HIV testing, and gender affirming care to Central Texans in need, regardless of race, creed, gender expression, or sexual orientation, has launched TeleKind, Austin’s first telehealth service offering quality sexual healthcare to patients through convenient and confidential video chat on a mobile device or computer.

Existing Kind Clinic patients will be able use TeleKind for follow-up appointments, prescription refills, and health care questions. TeleKind is available to all Kind Clinic patients, insured and uninsured

“Our mission through TeleKind is to ensure that sexual health is attainable for Central Texans, regardless of clinic proximity,” said Texas Health Action CEO Christopher Hamilton. “TeleKind will allow our expert providers to support our patients’ sexual wellness goals through a convenient, user-friendly platform they can access from anywhere.”

With almost 2,000 Kind Clinic patients making a significant commute to the clinic annually, video chat with the clinic’s sexual health experts ensures timely and consistent care for patients across Central Texas. “We take pride in providing our patients with a safe, supportive and empowering environment to address their sexual health concerns,” said Dr. Cynthia Brinson, Chief Medical Officer for Texas Health Action and the Kind Clinic. “TeleKind will allow us to provide that same personalized care for our patients without the commute.”

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Austin

AIDS Services of Austin Opens Moody Medical Clinic

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Ribbon Cutting for AIDS Service of Austin's Moody Medical Clinic
Ana Herrera, Joah Spearman, Kathie Tovo, Ora Huston, Paul E. Scott, Greg Casar, Jimmy Flannigan, Lloyd Doggett, and Ross Moody at Ribbon Cutting. Photo courtesy: AIDS Services of Austin

AIDS Services of Austin (ASA) celebrated the opening of the ASA Moody Medical Clinic with a ribbon cutting and tours of the new facilities for press and community supporters. In addition to ASA staff and board members, dignitaries attending included Representative Lloyd Doggett, Austin Mayor Pro Tem Kathie Tovo, City Council Members Greg Casar (District 4), Jimmy Flannigan (District 6), and Ora Houston (District 1).

ASA Moody Medical Clinic Ribbon Cutting
Paul E. Scott, Jimmy Flannigan, Kathie Tovo, and Ora Huston watch at Greg Casar reads city proclaimation at ribbon cutting. Photo courtesy AIDS Services of Austin.

Located at ASA’s main campus location at 7215 Cameron Road in North East Austin, the Moody Medical Clinic will provide primary care and HIV specialty care for those living with HIV as well as PrEP services and HIV/STI testing for those at high-risk of transmission. Clinical services will be integrated into ASA’s existing social and direct assistance programs in order to reduce barriers to care.

The ASA Moody Medical Clinic is now open! A special thank you to those that made this clinic a reality: Ross Moody, the…

Posted by AIDS Services of Austin on Thursday, September 13, 2018

“Our new ASA Moody Medical Clinic, working alongside the city and our community partners, will support Austin’s Fast-Track City initiative goals by increasing access to life-affirming care and help Austin get to zero new HIV transmissions,” says ASA Chief Executive Officer Paul Scott.

The clinic was made possible with a million dollar investment by Ross Moody and the Moody Foundation and $600,000 in community donations to support the construction, staffing, and first 6 months of clinical operations. The foundation also supported ASA’s Jack Sansing Dental Clinic.

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