Among issues affecting lesbian, gay, bisexual and transgender people, marriage rights and employment non-discrimination have been dominant attention-getters. But since the passage of the Affordable Care Act, it's worth taking a look at health care specifically as an LGBT issue.
Research from health groups all over the country shows that LGBT communities suffer disproportionately high rates of tobacco use, depression and other mental and behavioral health problems, some types of cancers, violence, and HIV infection. Yet, according to the Kaiser Family Foundation, only about 1/3 of LGBT people who make less than $47,000 a year have health insurance (whereas, about 15 percent of the total population is uninsured.) Indeed, access to care might be part of the problem. According to the Center for American Progress, about 67 percent of uninsured LGBT people had been without health insurance for more than two years, and about 60 percent of them had put off medical care in the last year because they couldn't afford it.
To talk about some of these health care disparities and the ways the ACA might be affecting LGBT communities, the National Lesbian and Gay Journalists Association organized a public forum last week hosted at WHYY's Philadelphia studios.
Panelists included Dr. Robert Winn, medical director of Mazzoni Center, Philadelphia's LGBT-focused health and social services nonprofit; Trudy Lieberman, a contributing editor to the Columbia Journalism Review, who writes about health reform and how it's covered in the media; and Katie Keith, a research analyst on the steering committee of Out2Enroll, a health insurance education and outreach program targeting LGBT populations. WHYY's Maiken Scott moderated the discussion.
The Supreme Court's rejection of the Defense of Marriage Act, coupled with passage of the ACA, gives access to health insurance options previously not available to LGBT consumers. Marketplaces, plans, insurance companies, health insurance navigators are not premitted to discriminate based on sexual orientation or gender identity. The trouble is, said Keith: "We don't know exactly what that means, how it's being interpreted and how it's playing out."
Same-sex couples in states where same-sex marriage is recognized can get financial subsidies no matter where they live. "So if you were married in Maryland and you live in Pennsylvania, you're married for the purposes of your health care application," Keith said. But private companies cannot be compelled to provide coverage to same-sex spouses; it depends on the laws of individual states.
Keith said that one of the issues she runs into is that insurance companies have a lot of discretion about how they define "family." In North Carolina, for example, where same-sex marriage is not legal, when Blue Cross realized same-sex couples were enrolling, they denied their applications. "There was an outcry. They got media attention. And Blue Cross eventually reversed their decision," said Keith.
She said a same-sex couple in western Pennsylvania experienced the same situation with Highmark, and after some bad press they also reversed their position.
Old problems and new for HIV-positive and transgender populations
A number of disparities are surfacing for people with HIV, as well. The ACA bans the exclusion of applicants on the basis of a pre-existing condition. "So HIV patients are no longer uninsurable," said Keith.
But insurance companies are still going to find a way to limit their claims risk, said Lieberman, "and people with HIV might have health problems that they don't want to insure."
And while it's true that someone can't be denied insurance because he or she is transgender, the panel said that the ban on pre-existing condition exclusions may have murky results for transgender consumers.
Winn explained that many plans prior to the ACA excluded coverage of the hormones, surgeries, and mental health care vital to the health of transgender people. "With the ACA, I'm not seeing that this is going to get better right away," he said. "There are still going to be people not getting what they need covered. Even if something is deemed 'medically necessary.'"
Another problem for transgender consumers is the requirement to choose a gender on an insurance application. "What your gender marker is legally, what it is you prefer — you cannot make that distinction," Winn said.
He related an anecdote about a patient of his, a transgender man who is insured, not through the ACA but through an employer-sponsored plan, who had to change his gender to female with his insurance company because his partner, who now has cervical cancer and who is also a transgender man, could not get his cervical cancer covered. "Because he's a guy, and he doesn't have a cervix, right?" Winn said. "Well, we all know that's not true, but insurance companies say you're a male and you have these parts, and they're covered. If you're a female, you have these parts, and they're covered. That's still out there in the insurance world. And because commercial products are what's being offered in the [ACA] marketplace, I'm predicting this is still going to happen to people."
One point that Leiberman drove home was the concept of cross-subsidization, citing complaints last year from ACA opponents about the law's pre-natal and maternity care requirements. Why should a woman with no plan to get pregnant — or a man — have to pay for such an insurance plan?
She used Medicare as an example: A 65-year-old without very many health issues pays premiums that go to subsidize an 85-year-old who has a lot of health problems.
In Europe and Canada, health systems that rely on this cross-subsidy are sacred, she said. "The sick are subsidized by the well. The old are subsidized by the young. And the poorer people are subsidized by the wealthy. And those subsidies are going on all the time."
They're also going on in the ACA, she explained. And the reason a 60-year-old woman who's never going to have a baby has to pay for pre-natal and maternity coverage is because "she's going to need some kind of coverage that a 35-year-old woman, who will have a baby, is going to pay for her — a cataract operation, for example."
It's really important, she said, to remember that the care that the transgender and HIV-positive communities need is being paid for by other people, and that's what the law intended to happen.
"The administration never explained that," Lieberman said. "Nobody ever explained that was going on, and I think, had that been explained, there would have been a lot less backlash from those, quote, [Obamacare] 'losers' who came on television to tell their stories."
So what happens when open enrollment ends on March 31?
"The Obamacare issue in the media is not going away any time soon," said Keith. "On April 1 they're going to be looking at enrollment numbers — were there any problems using the coverage that they got? — and I think we're still going to hear some of these really difficult stories you don't want to hear about. 'My friend isn't covered,' or 'I couldn't get this surgery,' and I think there's going to be a lot of growing pains. It remains to be seen, but were going to have to still keep talking about it. The good and the bad of it."
Eric Walter is the president of the Philadelphia chapter of NLGJA and one of the organizers of the public forum referenced in this article.