Receiving quality healthcare can often feel like a privilege for a select few in the U.S. For those in the LGBTQ community, their identity can be a lifelong barrier to care.
In 2022, one in eight LGBTQ Americans reported that they experienced discrimination from their health insurance provider, according to HealthCare.com, a search tool for healthcare consumers. Notably, bisexual, transgender, queer, pansexual, asexual and questioning individuals reported more discrimination than those who identify as gay or lesbian, possibly pointing to insurance companies’ limited understanding or acceptance of the queer community’s needs.
In practice, this discrimination can translate to an overall lack of coverage and access to gender-affirming medication and procedures, fertility treatments and medication for HIV prevention), says Dr. Corina Lelutiu-Weinberger, an associate professor at Columbia University and a social psychologist in the field of HIV prevention, mental health and substance use.
Read more:How to create an inclusive healthcare experience for the LGBTQ community
“The worst situation is for people of color who are sexual or gender minorities,” says Dr. Lelutiu-Weinberger. “They report the highest HIV rates, the highest suicide ideation rates and attempts. Bisexual people and non-binary people also seem to have some of the worst outcomes in health.”
These disparities start in childhood. The Trevor Project’s 2022 national survey found that LGBTQ youth of color had higher rates of suicide attempts than their white peers; 21% of Indigenous youth, 20% of Middle Eastern and Northern African youth, 19% of Black youth, 17% of multiracial youth and 16% of Latinx youth had attempted suicide compared to 12% of white youth, who also tied with Asian and Pacific Islander youth. Meanwhile, trans and nonbinary youth were two times as likely to experience depressive symptoms and attempt suicide than cisgender youth in the queer community, and bisexual youth were 11% more likely to consider suicide than gay or lesbian youth.
On top of that, gender-affirming care and mental health providers with the relevant background can be systematically hard to come by. Despite the Trevor Project noting a correlation between gender-affirming care and the reduction of suicide risk, four states (Alabama, Arkansas, Texas and Arizona) have placed restrictions on youth access to gender-affirming health care, and 11 other states may follow suit. In Texas, gender-affirming services for youth are defined as child abuse — parents who try to support their child could face having their child taken from them by the state. Alabama, Arkansas and Texas laws have been temporarily blocked by court rulings.
Read more:Are your 'inclusive' benefits excluding transgender employees?
The country remains divided in terms of health insurance inclusive protection, with 24 states and D.C. prohibiting transgender exclusion in health insurance plans, and 27 states having no law that demands LGBTQ inclusion from insurance carriers. Doctors pose another barrier: 29% of transgender individuals reported their healthcare provider refused to see them because of their perceived or actual gender identity, according to the Center for American Progress. This lays out a concerning domino effect, as little faith is placed in a healthcare system that cannot promise care for everyone, explains Dr. Lelutiu-Weinberger.
“Many LGBTQ people avoid or delay medical care because they've encountered a lot of discrimination already and fear that they will be discriminated against,” she says. “So they end up in the emergency room rather than accessing more preventive services, and urgent intervention is more expensive.”
And while the discrimination may not always directly come from a healthcare provider or state laws, insurance policies can do enough damage on their own. For example, under the Affordable Care Act, pre-exposure prophylaxis, also known as PrEP, is supposed to be completely covered by insurers as an effective preventive service, including the doctors appointments and lab tests associated with receiving PrEP. But insurers have continued to wrongly assign copays or make it appear as if patients will have to pay for the drug by improperly classifying it. A monthly supply of PrEP can be as much as $2,000, while quarterly lab tests and doctor visors can amount to $15,000 a year.
“It’s still not really free for many people in the U.S., and it’s very expensive because of pharmaceuticals and how they make money,” says Dr. Lelutiu-Weinberger. “A lot of people at risk for HIV are not able to afford PrEP on their own, and that’s discrimination.”
Dr. Lelutiu points out that the majority of insurance companies fail to cover fertility treatment as well, especially if an infertility diagnosis is required, which can be limited to heterosexual couples. This means an LGBTQ couple may have to pay $20,000 to over $100,000 to start a family.
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However, insurance may not even be a factor for many LGBTQ Americans. Research from Havard University underlines that due to employment discrimination impacting nearly half of all sexual minorities, they are less likely to have health insurance in the first place.
“This happens a lot in the LGBTQ community, and even more so in the transgender community — they cannot get hired, or when they do, they are not promoted or get fired,” says Dr. Lelutiu-Weinberger. “A lot of people will try to conceal their identity, but that discrimination remains in the workplace, which is connected to health insurance.”
Interestingly enough, the survey from HealthCare.com found that 32% feel insurance coverage is improving, while 44% do not believe it’s worsening or improving — and 13% say it’s getting worse. Dr. Lelutiu-Weinberger underlines that the survey did capture a lot of older gay white men, who may be in a position for more optimism. But personally, Dr. Lelutiu-Weinberger is uncertain if things are going to get better.
“I'm actually pessimistic about the state of this nation, with Roe V. Wade going away,” she says. “Healthcare access has the potential to worsen because of the current political fight and polarizing happening. It's all connected to the political system, who is in power, and their agenda.”
Dr. Lelutiu-Weinberger believes the future of healthcare will largely depend on what part of the country people live in, as states vary on laws and regulations surrounding human rights and health insurance. As for now, Dr. Lelutiu-Weinberger emphasizes the importance of documenting discrimination in healthcare and bringing awareness to what LGBTQ Americans are up against.
“Researchers are also advocates, and we will continue to document discrimination and request that it stops,” she says. “Most importantly, we need to work with health insurance companies and employers, because that's where change can happen. Things will improve if they change their policies to be more inclusive.”
