Just Read: Improved Health Insurance Coverage for LGB Adults; Gaps in Care Remain

This article, published in Health Affairs (@Health today, complements the other work I am reading, as part of my service on the AAMC Axis Committee (see: I said yes: AAMC Advisory Committee on Sexual Orientation, Gender Identity and Sex Development).

As part of that work, I’m reading the ground breaking report put out by the Association of American Medical Colleges in 2014 and in it, this quote:

LGBT individuals are twice as likely as others to lack health insurance. When coverage is obtained, insurance plans often do not include marital or family benefits for same-sex partners5 or do not cover medical care to support gender transition (also referred to as gender-affirming therapies).6 This disparity in insurance coverage has decreased with the implementation of the Affordable Care Act: the uninsured rates of LGBT adults dropped from 24.2 to 17.6 percent after the first annual enrollment period.7 However, even insured LGBT individuals may not have coverage for certain population-specific beneficial medical treatments, such as screening with high-resolution anoscopy, or gender-affirming therapies.

This paper helps answer the question: What’s happened since 2014?

And wow, things are happening so fast, stuff has happened since 2014.

There’s a Health Reform Monitoring Survey that’s fielded every quarter, and asks people if they identify as “gay”,”lesbian”,”bisexual” or “heterosexual.” The limitations of using that terminology to identify LGB people (and anyone who abstained or answered “other” were dropped from the analysis) aside, this survey tracks changes from the previous period of analysis (June-September 2013) and shows:

  • LGB and non-LGB adults with gains in insured status (90% for LGB)
  • Significant increase in “Usual Source of Care” (close to 80% for LGB)
  • No improvement in “Difficulty Accessing Care” + a continued disparity for LGB (16% non-LGB vs 23% LGB)
  • No improvement in Affordability measures for LGB + continued disparity in certain measures

Also, if you look at Exhibit 3 – there’s a significant difference (that’s worse) in reported health status and disability for LGB people.

This is even though there’s no significant difference in income or education level AND the LGB sample is younger than the non-LGB sample.

So, good news / bad news

Unexplained differences in health status still continue in this population despite greater coverage.

More LGB people are insured and in the health system. This creates a forcing function – the more contact the health system has with LGB people the more their needs will be understood. And, via the unconscious bias literature, the *possibility* that bias will diminish over time.

It’s not enough to have more LGB people in health care spaces to diminish bias – there has to be contact outside of these environments to debias the people who work in them, that’s where the connection made below by the others to the other policy change this year comes in.

I commend the authors on using terminology appropriately throughout – the survey did not assess the condition of people who may be transgender or gender non-conforming, so “LGB” is the right way to describe these results. And yet, the survey did not assess the condition of people who may be transgender or gender non-conforming.

I was also impressed that the authors mentioned two, not one, major policy changes that had an impact here:

Both the King v. Burwell and Obergefell v. Hodges rulings by the US Supreme Court, by continuing access to health insurance subsidies and upholding same-sex marriage, respectively, will expand the coverage options for LGB adults, potentially further improving coverage rates and, over time, access and affordability. The national legalization of same-sex marriage will in- crease coverage options for the LGB population by expanding access to coverage through employers, Medicaid, Medicare, and the Department of Veterans Affairs.

I think that’s cool. I’ve been saying for a long time that #EqualityEqualsHealth and its great that the health service researchers of our time are embracing and documenting this reality.

I had a feeling when I was taking these photographs while standing on the steps of the Supreme Court that love not only wins, it also creates better health for all.

That’s what we came here for – and we’re not done 🙂

SCOTUS Marriage Equality 2015 58126
SCOTUS Marriage Equality 2015 58126 (View on Flickr.com)
Ted Eytan, MD