Equity writ large is currently under attack by President Trump and his allies. Any committees or initiatives related to diversity, equity, and inclusion have been systematically dismantled across executive branch agencies, and an entire lexicon of inclusive language has been banned from use. Health equity initiatives have not been spared in this rollback. Despite this policy change, the problems of health disparities persist. In this moment, states may be better able to continue to advance health equity.
The Century Foundation, led by fellow Thomas Waldrop, produced a series of reports identifying the specific disparities for four groups and opportunities for states to continue to improve private insurance and systems to advance health equity. Those reports are summarized below. (Note that source citations are included in those reports and this commentary uses terms from the cited sources.)
LGBT Population
Read the full report, “Equitable Insurance Coverage and Access Can Advance LGBT Health.”
Nearly one in ten Americans identify as LBGTQ+ according to a 2024 Gallup poll. Members of the LGBT community are more likely to work in jobs that do not provide health coverage as a benefit. Although the Affordable Care Act (ACA) significantly reduced the uninsurance rate gap for the broader LGBT population, transgender and nonbinary adults remain more than twice as likely to be uninsured as their cisgender counterparts. Additionally, LGBT people of color are more likely to be uninsured than straight, cisgender people of color, LGBT white people, and straight, cisgender white people. LGB individuals are also more likely to rely on Medicaid for their health coverage.
LGBT individuals face barriers in affording health care services. LGBT adults are more likely to have difficulty paying a medical bill compared to straight cisgendered people. Additionally, LGBT individuals are more likely to have gone without needed medical care or to have postponed medical care due to challenges with cost. These affordability challenges relate to having less coverage as well as the high rates of poverty in the LGBT community. Transgender and LGBT people of color are the most likely to experience poverty in the LGBT community.
LGBT people are significantly more likely to contract HIV than straight, cisgender people. Additionally, some LGBT individuals require gender-affirming care to treat gender dysphoria. LGB individuals are also more likely to require mental health services due to discrimination and higher rates of screening.
Some steps that states can take to improve health equity for the LGBT population include:
- improving telehealth coverage for mental health services to allow LGBT patients to access providers that are more aligned with their needs who may not be present in their immediate geographic area;
- covering transportation costs required for individuals to access specialized and gender-affirming care;
- requiring providers to undergo LGBT training to equip them with knowledge of LGBT individuals’ unique health concerns, potentially as part of providers’ continuing medical education requirements or through network adequacy requirements, with insurers guaranteeing that providers underwent the required training; and
- partnering with LGBT community-based organizations on efforts such as vaccine education or health insurance outreach and enrollment efforts can help improve health outcomes in the community.
Women
Read the full report, “How States Can Relieve the Burden of Women’s High-Cost Private Health Coverage.”
While slightly over half of U.S. residents are women or girls, they experience the health system in different ways that justify policy change. The ACA included a number of provisions that lessened gender-based disparities in coverage and benefits, including banning gender rating and preexisting condition exclusions, and requiring coverage of preventive services. However, challenges with affordability for women remain. Women have higher health needs and utilization rates than men, owing to longer life expectancy, higher morbidity rates, and additional health care needs as related to pregnancy care, family planning, and menopause. Even when the cost of pregnancy-related care is excluded, women’s out-of-pocket spending on health care is about 18 percent higher than men’s. This higher cost poses a significant challenge for women as nearly 30 percent of women report that they have skipped or postponed care due to concerns about financial security. Additionally, women are more likely than men to stop taking needed medications due to concerns over costs.
Reproductive health needs of women are different from those of men, and policy to support their needs is in flux. The Dobbs v. Jackson Women’s Health Organization U.S. Supreme Court Decision overturned the federal right to abortion in 2022. Since then, many states have moved to ban or severely restrict abortion in their states. Additionally, abortion care is often exempted from coverage requirements. Over half of states prohibit the coverage of abortion in the state’s marketplace plans, and eleven states further prohibit abortion coverage in private plans. In this policy landscape, many women are required to pay out of pocket for abortions, which might cost anywhere from $580 to $2,000.
Coverage for contraception also, at times, presents a challenge for women. While the ACA eliminated deductibles, copays, and other out-of-pocket costs related to contraception, 13 percent of women are enrolled in plans exempt from the ACA requirements due to plans that were grandfathered in with these exceptions. Employers can also claim moral or religious exemptions to contraception coverage. These factors have led to 21 percent of women still paying some out of pocket costs for contraception.
For women that choose to give birth, the cost of childbirth-related services can prove prohibitively expensive. Maternity care “deserts”—areas where maternity care is limited or absent—have become increasingly common and may contribute to the high cost of care for maternity care services. These deserts are due, in part, to consolidation of health care providers, with private equity firms purchasing hospitals and closing less-profitable services such as maternity care. Additionally, providers specializing in women’s health care may avoid practicing in states where abortion is criminalized. These trends have disproportionately affected black women, as described below.
Some steps states can take to improve health equity for women include:
- ensuring coverage of reproductive health services,
- enhancing merger review laws to ensure access to services like maternity care, and
- leveraging a public option to lower costs.
Black Communities
Read the full report, “Advancing Health Equity for Black Communities Through Insurance Reform.”
About 14 percent of U.S. residents are Black. While the ACA significantly reduced the uninsured rate for Black individuals, they were 25 percent more likely to be uninsured compared to white individuals in 2024. Additionally, around 16 percent of Black adults that have health insurance are “underinsured”—that is, they face out-of-pocket expenses that constitute a significant portion of their income. Approximately 60 percent of Black adults report difficulty in affording care, compared to only 40 percent of white adults. Facing these challenges, both uninsured and insured Black patients reported skipping or postponing needed medical care due to cost.
Black patients also face discrimination and racism in health care. Eighteen percent of Black adults reported being treated unfairly by a health provider due to their race or ethnicity, compared to 11 percent of Hispanic adults and only 3 percent of white adults.
Several severe and chronic health conditions disproportionately impact Black individuals. Specifically, more than half of all Black adults have high blood pressure and Black adults are twice as likely to be diagnosed with diabetes compared with white adults.
Additionally, Black individuals, particularly, Black women, experience worse health outcomes on average compared to their white counterparts. For example, while Black women are less likely to develop breast cancer than white women, they are 35 percent more likely to die if they develop the condition. Additionally, Black women are significantly more likely to die in childbirth than white women.
Some steps states can take to improve health equity for the Black Americans include:
- reforming private insurance to limit cost sharing for the treatment of chronic conditions that disproportionately impact the Black community, such as diabetes;
- covering doula services in both Medicaid and private insurance and investing in alternative models of care for pregnant individuals; and
- reforming prior authorization to align with clinical standards of care to improve outcomes.
Immigrants
Read the full report, “Improving Affordability and Advancing Health Equity for Immigrants.”
About 14 percent of U.S. residents are immigrants, more than half of them in the country legally. Immigrants and especially undocumented immigrants have lower rates of health coverage compared with U.S. born or naturalized citizens. These low rates of coverage are typically due to a lack of eligibility for public sources of coverage, as undocumented immigrants often have limited options for accessing health insurance and lawfully present immigrants may still be subject to waiting periods. Immigrants have higher rates of poverty than citizens, which in turn makes it more difficult for immigrants to afford health care services. This has led to a significant portion of immigrants, one in five, reporting that they skipped or postponed needed medical care due to cost.
Most immigrants come from racial or ethnic minority communities and face the same challenges with the private health coverage system that U.S. citizens from those communities face. However, other challenges are unique to immigrants. Immigrants may struggle with how to navigate the U.S. health care system, which differs from that in their country of origin, and to make informed decisions based on the health information available to them. This unfamiliarity may lead to immigrants being more likely to use the emergency department rather than primary care services, creating accessibility and affordability barriers to care.
Immigrants also fear that accessing health care could affect their status in the United States. During the first Trump administration, the administration issued a final rule known as “Public Charge.” This rule would have allowed immigration officials to consider whether immigrants who participated in Medicaid and other safety net programs were “likely to become a public charge.” This rule had a chilling effect toward immigrants or individuals with noncitizen immigrants in their household on applying for health insurance. While the Biden administration rescinded the public charge rule in 2021, the second Trump administration has made it clear its intent to use systems, including the health system, to deport immigrants.
Some steps states can take to improve health equity for immigrants include:
- ensuring private insurers enroll otherwise eligible people without regard to their immigration status;
- providing culturally responsive care training, including language access requirements, through network adequacy requirements; and
- prioritizing direct communication with immigrant communities regarding policy changes and directly engaging community-based partners who are partners in supporting individuals getting needed health care.
Conclusion: State Actions to Improve Health Equity Across Groups
While some of the variation in health outcomes across groups are specific to them, others reflect gaps and flaws in the health system that, if addressed, could reduce disparities across all of them. These include:
- Improving mental health coverage, including some required coverage below the deductible. A common co-occurring condition with physical health disparities is anxiety and depression. States have a number of options to improve private health coverage for mental health which would have broad-based benefits.
- Offering a public plan option. Public options can provide an avenue for states to target coverage expansion efforts and improve the affordability of health coverage for marginalized populations.
- Improving merger review process for health care providers. Hospital consolidation has contributed to rising health care costs without associated improvement in patient care. In addition to sharpening the focus on reducing costs, hospital mergers could be reviewed for any potential impact on health equity.
States actions on these policies would likely have little impact on state budgets—and, in some cases, could lower state costs by reducing uncompensated care, expensive care that could be prevented with early intervention, and lower prices.
This series of reports focused on private insurance, but a common denominator is the role that Medicaid plays in the health of disadvantaged people in this country. Expanding the program and protecting it from changes that would reduce coverage is important to health equity as well.
Tags: lgbt, health equity, blackmaternalhealthcare, health coverage, women's health
Not Gone: Health Disparities and What States Can Do About Them
Equity writ large is currently under attack by President Trump and his allies. Any committees or initiatives related to diversity, equity, and inclusion have been systematically dismantled across executive branch agencies, and an entire lexicon of inclusive language has been banned from use. Health equity initiatives have not been spared in this rollback. Despite this policy change, the problems of health disparities persist. In this moment, states may be better able to continue to advance health equity.
The Century Foundation, led by fellow Thomas Waldrop, produced a series of reports identifying the specific disparities for four groups and opportunities for states to continue to improve private insurance and systems to advance health equity. Those reports are summarized below. (Note that source citations are included in those reports and this commentary uses terms from the cited sources.)
LGBT Population
Read the full report, “Equitable Insurance Coverage and Access Can Advance LGBT Health.”
Nearly one in ten Americans identify as LBGTQ+ according to a 2024 Gallup poll. Members of the LGBT community are more likely to work in jobs that do not provide health coverage as a benefit. Although the Affordable Care Act (ACA) significantly reduced the uninsurance rate gap for the broader LGBT population, transgender and nonbinary adults remain more than twice as likely to be uninsured as their cisgender counterparts. Additionally, LGBT people of color are more likely to be uninsured than straight, cisgender people of color, LGBT white people, and straight, cisgender white people. LGB individuals are also more likely to rely on Medicaid for their health coverage.
LGBT individuals face barriers in affording health care services. LGBT adults are more likely to have difficulty paying a medical bill compared to straight cisgendered people. Additionally, LGBT individuals are more likely to have gone without needed medical care or to have postponed medical care due to challenges with cost. These affordability challenges relate to having less coverage as well as the high rates of poverty in the LGBT community. Transgender and LGBT people of color are the most likely to experience poverty in the LGBT community.
LGBT people are significantly more likely to contract HIV than straight, cisgender people. Additionally, some LGBT individuals require gender-affirming care to treat gender dysphoria. LGB individuals are also more likely to require mental health services due to discrimination and higher rates of screening.
Some steps that states can take to improve health equity for the LGBT population include:
Women
Read the full report, “How States Can Relieve the Burden of Women’s High-Cost Private Health Coverage.”
While slightly over half of U.S. residents are women or girls, they experience the health system in different ways that justify policy change. The ACA included a number of provisions that lessened gender-based disparities in coverage and benefits, including banning gender rating and preexisting condition exclusions, and requiring coverage of preventive services. However, challenges with affordability for women remain. Women have higher health needs and utilization rates than men, owing to longer life expectancy, higher morbidity rates, and additional health care needs as related to pregnancy care, family planning, and menopause. Even when the cost of pregnancy-related care is excluded, women’s out-of-pocket spending on health care is about 18 percent higher than men’s. This higher cost poses a significant challenge for women as nearly 30 percent of women report that they have skipped or postponed care due to concerns about financial security. Additionally, women are more likely than men to stop taking needed medications due to concerns over costs.
Reproductive health needs of women are different from those of men, and policy to support their needs is in flux. The Dobbs v. Jackson Women’s Health Organization U.S. Supreme Court Decision overturned the federal right to abortion in 2022. Since then, many states have moved to ban or severely restrict abortion in their states. Additionally, abortion care is often exempted from coverage requirements. Over half of states prohibit the coverage of abortion in the state’s marketplace plans, and eleven states further prohibit abortion coverage in private plans. In this policy landscape, many women are required to pay out of pocket for abortions, which might cost anywhere from $580 to $2,000.
Coverage for contraception also, at times, presents a challenge for women. While the ACA eliminated deductibles, copays, and other out-of-pocket costs related to contraception, 13 percent of women are enrolled in plans exempt from the ACA requirements due to plans that were grandfathered in with these exceptions. Employers can also claim moral or religious exemptions to contraception coverage. These factors have led to 21 percent of women still paying some out of pocket costs for contraception.
For women that choose to give birth, the cost of childbirth-related services can prove prohibitively expensive. Maternity care “deserts”—areas where maternity care is limited or absent—have become increasingly common and may contribute to the high cost of care for maternity care services. These deserts are due, in part, to consolidation of health care providers, with private equity firms purchasing hospitals and closing less-profitable services such as maternity care. Additionally, providers specializing in women’s health care may avoid practicing in states where abortion is criminalized. These trends have disproportionately affected black women, as described below.
Some steps states can take to improve health equity for women include:
Black Communities
Read the full report, “Advancing Health Equity for Black Communities Through Insurance Reform.”
About 14 percent of U.S. residents are Black. While the ACA significantly reduced the uninsured rate for Black individuals, they were 25 percent more likely to be uninsured compared to white individuals in 2024. Additionally, around 16 percent of Black adults that have health insurance are “underinsured”—that is, they face out-of-pocket expenses that constitute a significant portion of their income. Approximately 60 percent of Black adults report difficulty in affording care, compared to only 40 percent of white adults. Facing these challenges, both uninsured and insured Black patients reported skipping or postponing needed medical care due to cost.
Black patients also face discrimination and racism in health care. Eighteen percent of Black adults reported being treated unfairly by a health provider due to their race or ethnicity, compared to 11 percent of Hispanic adults and only 3 percent of white adults.
Several severe and chronic health conditions disproportionately impact Black individuals. Specifically, more than half of all Black adults have high blood pressure and Black adults are twice as likely to be diagnosed with diabetes compared with white adults.
Additionally, Black individuals, particularly, Black women, experience worse health outcomes on average compared to their white counterparts. For example, while Black women are less likely to develop breast cancer than white women, they are 35 percent more likely to die if they develop the condition. Additionally, Black women are significantly more likely to die in childbirth than white women.
Some steps states can take to improve health equity for the Black Americans include:
Immigrants
Read the full report, “Improving Affordability and Advancing Health Equity for Immigrants.”
About 14 percent of U.S. residents are immigrants, more than half of them in the country legally. Immigrants and especially undocumented immigrants have lower rates of health coverage compared with U.S. born or naturalized citizens. These low rates of coverage are typically due to a lack of eligibility for public sources of coverage, as undocumented immigrants often have limited options for accessing health insurance and lawfully present immigrants may still be subject to waiting periods. Immigrants have higher rates of poverty than citizens, which in turn makes it more difficult for immigrants to afford health care services. This has led to a significant portion of immigrants, one in five, reporting that they skipped or postponed needed medical care due to cost.
Most immigrants come from racial or ethnic minority communities and face the same challenges with the private health coverage system that U.S. citizens from those communities face. However, other challenges are unique to immigrants. Immigrants may struggle with how to navigate the U.S. health care system, which differs from that in their country of origin, and to make informed decisions based on the health information available to them. This unfamiliarity may lead to immigrants being more likely to use the emergency department rather than primary care services, creating accessibility and affordability barriers to care.
Immigrants also fear that accessing health care could affect their status in the United States. During the first Trump administration, the administration issued a final rule known as “Public Charge.” This rule would have allowed immigration officials to consider whether immigrants who participated in Medicaid and other safety net programs were “likely to become a public charge.” This rule had a chilling effect toward immigrants or individuals with noncitizen immigrants in their household on applying for health insurance. While the Biden administration rescinded the public charge rule in 2021, the second Trump administration has made it clear its intent to use systems, including the health system, to deport immigrants.
Some steps states can take to improve health equity for immigrants include:
Conclusion: State Actions to Improve Health Equity Across Groups
While some of the variation in health outcomes across groups are specific to them, others reflect gaps and flaws in the health system that, if addressed, could reduce disparities across all of them. These include:
States actions on these policies would likely have little impact on state budgets—and, in some cases, could lower state costs by reducing uncompensated care, expensive care that could be prevented with early intervention, and lower prices.
This series of reports focused on private insurance, but a common denominator is the role that Medicaid plays in the health of disadvantaged people in this country. Expanding the program and protecting it from changes that would reduce coverage is important to health equity as well.
Tags: lgbt, health equity, blackmaternalhealthcare, health coverage, women's health