This week I am proud to highlight two recent studies showing that adults identifying as lesbian, gay, bisexual, and transgender (LGBT) have made significant gains in coverage and access to care over the past several years since the Affordable Care Act (ACA) and its Medicaid expansions have taken effect.
LGBT adults have historically faced serious barriers to health insurance coverage—before the ACA, insurers could deny coverage to LGBT adults, deny coverage to people with conditions like HIV that are more prevalent among LGBT individuals, deny spousal coverage to same-sex partners on employer-sponsored plans, and exclude coverage or charge higher rates for certain services like gender-affirming care. ACA implementation brought important non-discrimination protections, laid out Essential Health Benefits that insurers are required to cover, and allowed states to expand Medicaid to low-income adults up to 138% of poverty (the 2015 Obergefell v. Hodges Supreme Court decision legalizing same-sex marriage also means that insurers must now offer the same coverage to all spouses. For more info about LGBT adults and private health insurance, check out this blog from our friends at Georgetown’s Center on Health Insurance Reforms). Medicaid expansion has contributed to widespread coverage gains and more so it’s not surprising that LGBTQ+ individuals have also benefitted, but two new studies show just how much.
A recent study from Vanderbilt University researchers in Health Services Research, using data from the Census Bureau’s 2008-2018 American Community Survey (ACS), finds that ACA Medicaid expansions increased the likelihood that both men and women in same-sex relationships had health insurance coverage:
- After expansion, men in same-sex relationships were 54% more likely to have Medicaid coverage compared to 2008-2009, and 7% more likely to have any health insurance coverage.
- After expansion, women in same-sex relationships were 77% more likely to have Medicaid, 9% more likely to have any health insurance, and even 11% more likely to have Medicaid than women in different-sex relationships.
- The catch: the ACS doesn’t actually ask respondents about their sexual orientation. Researchers used household relationship variables to look for same-sex married and cohabiting couples, but using those relationships as a proxy for LGBT identity could miss some bisexual and single sexual minority individuals or could mistakenly identify some couples. Previous research has shown that married people, and married women in particular, benefitted from Medicaid expansions more than singles, so these results could overestimate coverage gains.
Another recent study in Health Affairs digs a little deeper. Researchers from Harvard University, the University of Michigan, and Massachusetts Institute of Technology (MIT) use data from the Urban Institute’s Health Reform Monitoring Survey for 2013-2019 to analyze coverage and access to care for adults who self-identified as LGBT. They found that:
- Among non-LGBT adults, coverage spiked after the ACA was implemented and then leveled off (from 84.2% covered in 2013 to 89.7% in 2014-2016 and 90.6% in 2017-2019), but coverage continued increasing for LGBT adults (from 75.9% in 2013 to 85.0% in 2014-2016 to 91.2% in 2017-2019).
- By 2017-2019 period, LGBT adults were actually statistically significantly more likely to have health insurance coverage than non-LGBT adults (91.2% vs. 90.6%).
- Partnered LGBT adults saw the biggest coverage gains. Although they had the lowest coverage rates in 2013 (75.0%), by 2017-2019 the coverage gap between LGBT and non-LGBT partnered adults had closed completely with about 92% of both groups covered.
- But, LGBT singles also saw larger coverage gains (from 76.7% in 2013 to 90.3% in 2017-2019) than non-LGBT singles (79.8% in 2013 to 87.6% in 2017-2019).
- On measures of access to health care, LGBT adults also saw larger improvements than non-LGBT adults in the share with a usual source of care, the share who reported trouble paying medical bills, and the share who went without needed medical care because of cost. The gap between LGBT and non-LGBT adults with a usual source of care closed by the 2017-2019 period, but disparities across the other measures remain.
These studies provide an important, encouraging look at coverage and access to care for a group we have historically little data about. Despite these coverage gains, LGBT adults still face notable challenges to accessing care and often have worse health outcomes than non-LGBT groups, so there is still work to be done to eliminate these disparities. But it’s worth celebrating this progress towards greater health equity.