LGBT people in the United States face significant health disparities compared to straight, cisgender people. These disparities are driven by a variety of reasons, including systemic bigotry and inequitable coverage that fails to provide LGBT people with affordable access to care that meets their unique health needs. In particular, the transgender community faces widespread discrimination and a coordinated push to ban gender-affirming care, especially for transgender or non-binary youth.
While LGBT health equity cannot be divorced from these efforts to undermine access to care, the focus of this report is specifically on how unaffordable health care and health coverage impacts the LGBT population. The report begins by describing differences in coverage rates for LGBT people, after which it highlights how high provider prices drive unaffordable care and coverage. It then describes the unique health challenges that LGBT people face stemming from these affordability challenges and the policy solutions that can ameliorate them.
Author’s note: This report uses terms from cited sources. For example, the brief uses the term “LGB” to discuss a source which only examined sexual orientation. The report uses the term “LGBT” in contexts outside of cited sources.
Affordable Coverage Remains a Challenge for LGBT People
Affordable health coverage that supports the ability to access needed health services is essential to achieving true health equity. While progress has been made since the passage of the Affordable Care Act (ACA), disparities in coverage rates and struggles with affordable coverage remain for the LGBT community.
LGBT people often work lower-paying jobs in part because of employment discrimination. These jobs are less likely to provide health coverage as a benefit, and prior to the nationwide legalization of same-sex marriage in 2015, LGBT individuals were often unable to obtain coverage through a spouse’s job. Some progress at improving LGBT people’s coverage rates has been made, however. A study published in Health Affairs in June 2023 found that the coverage expansions as a result of the ACA, combined with the nationwide legalization of same-sex marriage in 2015, closed much of the disparity in coverage rates between LGB and straight people by 2019. A 2021 report by the Department of Health and Human Services (HHS) found a similar result: 12.7 percent of LGB people were uninsured in 2019, compared to 11.4 percent of straight people, as shown in Figure 1.
This high-level view, however, hides variation within the LGBT community. For example, the 2021 HHS report found that Black LGB people were more likely to be uninsured than Black straight people. While the report did not have any data on gender identity, making any analysis of transgender people’s health coverage impossible, a recent survey by the Center for American Progress (CAP) did. CAP’s survey found that transgender or nonbinary adults were more than twice as likely as cisgender adults to report being uninsured in 2022, and the same survey echoed the finding that LGBT people of color were more likely to report being uninsured than straight, cisgender people of color, LGBT white people, and straight, cisgender white people. Figures 2 and 3 show the differences in coverage rates between Black LGB people and Black straight people and between transgender or non-binary people and cisgender people.
Examining the sources of coverage that LGBT people use is also essential to understanding the challenges they face. In 2021, HHS found that LGB people were significantly more likely to be enrolled in Medicaid than straight people, though the majority of both LGB people and straight people were enrolled in private coverage. The trend was also found in a more recent Health Affairs study, as shown in Figure 4.
These higher levels of uninsurance and higher levels of Medicaid enrollment are especially concerning during the “unwinding” of the pandemic-related continuous coverage requirement. As part of the Families First Coronavirus Response Act, Congress provided states with enhanced funding for their Medicaid programs if they agreed to maintain their eligibility requirements for Medicaid and to not disenroll beneficiaries. This requirement ended on March 31, 2023, resulting in states redetermining many Medicaid enrollees’ eligibility for the first time in years. LGBT people’s higher likelihood of having Medicaid as a coverage source means that inappropriate disenrollment during this unwinding period may disproportionately leave LGBT patients without coverage.
As with straight, cisgender people, however, the overwhelming majority of LGBT people receive their health coverage through private sources. In particular, the nationwide legalization of same-sex marriage enabled many LGBT people to newly receive employer-sponsored insurance through a spouse’s job, and the expanded affordability of marketplace coverage drove individual market enrollment.
High Prices Drive Unaffordability
Even among LGBT people who have health coverage, however, that coverage doesn’t always make needed care affordable. At the root of this unaffordable care is high provider prices and market power. This is especially a concern for commercial insurance, which pays on average nearly twice as much as Medicare does for hospital services. These high prices charged, especially in hospital settings, are the drivers of increasing health care costs. These unsustainable prices drive up premiums and out-of-pocket costs, and the ensuing affordability issues disproportionately burden LGBT people.
In 2019, LGBT people were about 30 percent more likely to have trouble paying a medical bill and about 40 percent more likely to have gone without needed medical care because they could not afford it, as compared to straight, cisgender people. The 2022 CAP survey found even more dramatic disparities in access: in 2022, LGBTQI+ people were more than twice as likely to report postponing or not trying to get needed medical care because they could not afford it. As with coverage rates, the survey also found that transgender or nonbinary people and LGBTQI+ people of color, as well as disabled people, were more likely to have delayed care due to cost.
In 2019, LGBT people were about 30 percent more likely to have trouble paying a medical bill and about 40 percent more likely to have gone without needed medical care because they could not afford it.
This disparity in affordability is in part due to higher rates of poverty among LGBT people, driven by discrimination and accompanying unemployment and underemployment rates. Transgender people and LGBT people of color were the most likely to experience poverty, emphasizing the way individual and systemic bigotry drives these disparities. Figures 5 and 6 show the poverty rate for LGBT people compared to straight, cisgender people and cisgender LGB people, as well as among LGBT people by race and ethnicity.
LGBT People Also Face Unique Health Challenges
In addition to challenges resulting from the health coverage and access system itself, LGBT people also face a higher likelihood of needing care for specific health conditions compared to straight, cisgender people people. This section describes three of these: HIV, gender-affirming care, and mental health care.
HIV is a virus that attacks the human body’s immune system and was discovered in the United States in the 1980s. One of the primary ways that HIV is spread is through sexual contact, and while all people are susceptible to the disease, men who have sex with men (MSM) have been the most frequently documented transmitters and sufferers in the United States. While rates of HIV have fallen in recent years, in the United States, LGBT people are still significantly more likely to contract HIV than straight, cisgender people. In 2021, gay, bisexual, and other MSM accounted for 67 percent of new U.S. HIV diagnoses, with Black and Hispanic MSM accounting for 40 percent and 29 percent of new diagnoses, respectively. These rates of infection often stem from an unawareness of one’s HIV status, which may be due to recent infection, not getting tested due to underestimation of personal risk, or fewer opportunities to get tested.
In particular, the impact of a lack of coverage on HIV testing and treatment can be seen through the lens of Medicaid expansion. The majority of new diagnoses in 2021 were in the South, the region which contains 70 percent of the states which have not yet expanded Medicaid. More equitable coverage policies would significantly improve access to HIV testing, though stigma and affordability barriers may still persist.
Even without a diagnosis, the increased risk of HIV itself contributes to increased health needs and economic burden. Pre-exposure prophylaxis (PrEP) drugs are medications that can prevent transmission of HIV via sex when taken as prescribed. While these drugs are extremely effective, they can have negative side-effects, including kidney and liver damage in some people. PrEP drugs can also be prohibitively expensive, especially for uninsured patients. A thirty-day supply of Truvada, the first PrEP drug approved by the FDA, costs more than $1,800 without insurance.
A thirty-day supply of Truvada, the first PrEP drug approved by the FDA, costs more than $1,800 without insurance.
Another type of care with considerably higher stakes for LGBT people and to which LGBT people face heightened barriers is known as gender-affirming care. Gender-affirming care is a wide umbrella term that includes many services that both cisgender and transgender people receive. For example, breast reconstruction for cisgender women who had mastectomies to treat breast cancer is a form of gender affirming care, as is breast augmentation for transgender women. That said, transgender people are more likely to require gender-affirming care to achieve their best health.
Gender-affirming care is often used to treat gender dysphoria: “a marked incongruence between one’s experienced/expressed gender and their assigned gender… associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.” It is important to note that not every transgender person experiences gender dysphoria and that not every transgender person undergoes any specific form of gender-affirming care, but for those that do, its impact is often significant and positive.
For example, a recent study by researchers at the University of Washington’s School of Public Health found that access to hormone replacement therapy and puberty blockers for youth ages 13 to 20 was associated with a nearly 60 percent lower likelihood of moderate to severe depression and nearly 75 percent lower likelihood of self-harm or suicidal thoughts compared to those who did not have access to these services. This trend is found throughout the literature, leading the American Psychological Association to institutionally support access to these services in 2008.
Mental Health Services
The final condition-related treatment that this paper discusses is mental health care. LGB people are more than twice as likely to have a mental health condition at some point in their life than straight people, and transgender people are more than three times as likely to have a mental health condition than cisgender people. There are many reasons why this is the case. First, LGBT people, especially transgender people, face higher rates of individual and systemic discrimination than straight, cisgender people. Second, transgender people are generally required to undergo a mental health assessment before beginning any medical transition, which would necessarily identify other mental health conditions they may have.
These mental health conditions are concerning in their own right, but they also contribute to worse overall health and a less efficient health system. For example, depression can increase the risk of diabetes, heart disease, and stroke. People with mental health conditions may also turn to substance abuse as a form of “self-medication,” potentially exacerbating other physical health conditions and increasing their risk for infectious diseases like HIV or hepatitis. This approach can also lead to further mental health conditions, potentially creating a vicious cycle.
State-Level Policies Can Reduce LGBT Health Care Inequities
States can work to promote access to the needed care for all of these conditions. For example, states should require insurers to accommodate the reality that the providers in a given region may currently be unable to provide the care that LGBT people need. For example, mental health providers in a given region may not accept new patients, but other providers in the state may. Improving telehealth coverage for mental health services can ensure that LGBT people can access the care they need without being limited by where they live within a state.
Similarly, providers qualified to perform some gender-affirming surgeries are relatively limited, often operating out of dedicated gender-affirming care practices. In these cases, states should require insurers to cover not only the care provided, but also the transportation and other related costs for a patient to be able to access this care. As with the other coverage mandates discussed, the benefits of accessing gender-affirming care far outweigh the increased costs associated with new coverage requirements.
Finally, states can ensure that health care providers are able to meet the health needs of LGBT people in ways that affirm their identities through two essential, though overlapping, components: knowledge of the unique health needs of LGBT people and the effective treatments for those needs, and a culture that ensures LGBT people feel comfortable discussing those needs with their providers.
For example, states can include LGBT cultural sensitivity training as part of providers’ continuing medical education requirements, ensuring that all providers are knowledgeable about LGBT people’s unique health needs. Similarly, states can include similar requirements in their insurance network laws. Colorado is a state that has led in efforts to ensure that insurers have affirming networks: as part of a public option law passed in 2021, insurers for the public option are required to ensure their plans are “culturally responsive.” Critically, this law requires insurers to provide cultural competency training to providers and staff and report to the state the level of in-network providers who have undergone such training. At least 50 percent of in-network providers must have taken this training in 2023, and at least 90 percent of providers must have done so by January 1, 2025.
However, these efforts should not solely rely on insurer training to measure accomplishment. In addition to cultural competency training, states should require insurers to survey enrollees to ensure that these efforts are making a meaningful difference in how LGBT patients are treated by providers.
How States Can Address Affordability Challenges
States must also ensure that LGBT people can access needed services, not just simply that providers are willing to deliver them. Well-designed, affordable health coverage can help ensure that LGBT people can access the health services they need without cost burdens. This section describes a variety of strategies states should use to improve outcomes for LGBT people and achieve a more efficient health care delivery system, applying TCF’s Health Coverage Equity Framework.
Expand Affordable Health Coverage
First, states should take efforts to promote affordable health coverage. This is especially critical during the unwinding of the Medicaid continuous coverage requirement. As discussed above, LGBT people are more likely than straight, cisgender people to be enrolled in Medicaid, putting them at heightened risk of losing coverage during this period. The most recent data show that nearly three in four people disenrolled from Medicaid during this process were disenrolled due to procedural reasons, not due to changes in income. States should improve their Medicaid redetermination practices to ensure that as few people are procedurally disenrolled as possible, and they should also work to connect disenrolled beneficiaries with new sources of coverage.
The most recent data show that nearly three in four people disenrolled from Medicaid during this process were disenrolled due to procedural reasons, not due to changes in income.
Ensuring consistent coverage can take multiple forms. The ten states that have yet to expand Medicaid should do so, ensuring that the lowest-income residents have a valuable, affordable form of health coverage. Additionally, the extended subsidy enhancement for marketplace coverage through the American Rescue Plan makes marketplace plans a source of coverage that states should especially prioritize. States could also enact a public option with LGBT people as one of the targeted populations. As previous TCF research has highlighted, public options can be a powerful tool for states looking to target coverage expansion efforts or improve the affordability of health coverage for marginalized populations.
Working with trusted LGBT community organizations can be an effective way to promote this coverage source. For example, the mpox outbreak in 2022 disproportionately impacted the LGBT community. In response, the District of Columbia health department worked with Whitman Walker Health, a local LGBT clinic and advocacy group, to update the community on the outbreak, which led to high rates of vaccination within the community. A similar approach to educating patients on the need to redetermine their Medicaid eligibility and available coverage sources if they are no longer eligible could achieve similar success at working toward universal coverage among LGBT people.
Lower Health Care Prices to Promote the Use of Coverage
In expanding coverage, however, states should include some level of downward price pressure to make the health care system more affordable for patients. As discussed above, the high cost of care is the basis for both high premiums and unaffordable cost-sharing for patients. This section discusses a few options that states have to lower health care costs and promote LGBT health equity.
One option states have is through insurer rate reviews. At its core, rate review requires health insurers to justify increases in their premiums above a certain amount, with the goal being to reduce overall cost growth. Importantly, taking this approach can help ensure that insurer savings are passed onto consumers. By requiring insurers to justify rate increases, rather than simply requiring value-based payment approaches, states can ensure that systems-level savings return to patients as lower premiums or cost-sharing reductions. If we’re to truly advance health equity, promoting a more efficient health system must be paired with ensuring patients feel the benefit of that efficiency.
The rate review policy is one of the Affordable Care Act’s major features, and many states have similar programs. Rhode Island has been a leader on this front: the state passed a law in 2004 requiring the Office of the Health Insurance Commissioner to review rates on a variety of factors, including “public interest.”
As part of its carrying out of this charge, the office has required insurers since 2010 to limit effective price increases for hospital services to Medicare’s price index plus 1 percent, as well as shift their payments to value-based payment arrangements. A 2019 Health Affairs study found that these policies were extremely effective, with fee-for-service spending decreasing by around 8 percent. The same study found that health care utilization and quality metrics were generally unchanged, suggesting that this policy can meaningfully lower prices without reducing patients’ ability to receive the high-quality care they need.
Enhanced rate review could be combined with the coverage expansion policies discussed earlier, especially public option programs. Every state that has enacted a public option to date has included some method of cost-containment in its program. By also including a public interest charge in these rate review processes, states can enact guard rails to ensure that lowered health care spending does not come at the price of worsened access to health care services. For example, spending meant to improve access to PrEP services could be treated differently under these programs.
Another option states can take is to enact a robust merger review process for health care providers. In recent years, hospital consolidation has significantly accelerated, and this consolidation contributes to the rise of health care costs. While proponents of consolidation argue that it improves patient outcomes, the evidence suggests mergers only increase costs, without improving quality of care received or efficiency of health care systems.
In order to combat this negative impact on the health care system, many states have implemented merger reviews for health providers, especially hospitals. Under these laws, health care entities are required to notify state entities in advance of a merger, after which the state can approve, reject, or place conditions on the proposed merger. While antitrust enforcement is often viewed solely through the lens of prices, these laws can also promote LGBT people’s health equity. For example, Oregon passed a law in 2021 allowing the Oregon Health Authority to review and block a merger it believes will reduce access to care through the state. Rhode Island passed a similar law in 2022, allowing the state’s attorney general to block or impose conditions on mergers that are not in the public interest.
Applying an LGBT lens to these public interest requirements could help ensure that LGBT people continue to have access to care while also ensuring that provider market power does not arbitrarily inflate prices. For example, the U.S. Conference of Catholic Bishops issued guidance to Catholic hospitals in March 2023 prohibiting the delivery of gender-affirming care. More than one in seven patients receive care from these hospitals, and if they become the only health provider in a region through a hospital merger, LGBT people’s access to necessary care could be undermined. Including equity-focused measures of access to care within merger review processes can ensure that health prices grow at sustainable rates and that LGBT people can continue to access care. Hospitals must be held accountable for ensuring marginalized groups are not harmed before any proposed mergers are approved.
Require Coverage without Burdensome Cost-Sharing
Beyond simply ensuring coverage, however, states should also work to ensure that the coverage is equitable and affordable. Health coverage that doesn’t cover the services one needs—or covers it with prohibitive cost-sharing—provides minimal benefit to patients. Below are several examples of services that should be prioritized by states, potentially making use of the savings achieved through lower prices in the overall health system.
One of the most significant ways that states can ensure that coverage provides meaningful access to care for LGBT people is by mandating coverage for both PrEP and gender-affirming care. To ensure that this coverage requirement supports access, however, states should clarify that this coverage must not include cost-sharing and must include ancillary services. For example, in order to receive a PrEP prescription, patients must regularly get tested for HIV and have their kidney function assessed to ensure that the drugs are not having adverse side effects.
In 2021, the U.S. Preventive Services Task Force required insurers to cover these tests as part of its requirement for insurers to cover PrEP, rightly acknowledging that these ancillary services are functionally part of accessing a PrEP prescription. Taking a similar approach in state law for PrEP will help ensure that everyone especially at risk for infection, and MSM in particular, have access to these essential medicines. States should also require insurers to cover gender-affirming care, as well as the mental health and other appointments necessary to access that care.
The costs for gender-affirming care are often less than the cost of other conditions that properly provided gender-affirming care can help avoid, such as depression.
Promoting patient access to these services will not only improve LGBT people’s health outcomes, but it will also promote a more efficient health care system. The cost of generic PrEP is about $30 per month, while the estimated lifetime cost of treating HIV is more than $420,000. Similarly, the costs for gender-affirming care are often less than the cost of other conditions that properly provided gender-affirming care can help avoid, such as depression. Hormone replacement therapy, the most common form of gender-affirming care, only costs around $120 per year for testosterone and around $150 per year for estrogen, compared to around $6,500 per year to treat major depressive disorder.
LGBT people face unique health challenges, and states are in a position to address them. Working to improve coverage rates among LGBT people, especially during the unwinding of the Medicaid continuous coverage requirement and the associated risk of losing coverage altogether, is an essential first step. States should work with trusted allies of the LGBT community to connect those who are no longer eligible for Medicaid with alternative sources of coverage, such as employer-sponsored insurance, marketplace coverage, or even a new public option.
In order for this coverage to improve outcomes, however, LGBT people must be able to afford the care it covers. Working to ensure that the root price of health care is reigned in is essential to promoting affordability, as well as lowering premiums for consumers. As states implement these strategies, reinvesting the savings into other measures that promote access, such as limiting cost-sharing, can ensure that LGBT people receive the care they need.
In a time when LGBT people’s rights, especially as they relate to health care, are under attack across the country, states have an opportunity and an obligation to work to support LGBT people as best they can. Promoting universal coverage and affordable access to needed care is a critical way to do so.