The COVID-19 pandemic has had devastating impacts on the United States’ public health and health care infrastructure. As of January 26, more than 25 million Americans had tested positive for—and more than 415,000 had died of—the coronavirus, while hospitals and health care professionals across the country remain overwhelmed and 2 to 3 million workers have lost their health insurance due to job losses. These crises are compounding existing disparities experienced by LGBTQ people, who already face significant challenges and inequities related to stigma and discrimination in terms of their physical and mental health as well as their ability to access health insurance and health care. In particular, the pandemic is hitting hardest among those LGBTQ people who live at the intersection of multiple identities that have historically been discriminated against, including LGBTQ people of color and those in low-income households, many of whom lacked health coverage prior to the pandemic.
Due to the dearth of clear guidance from the federal government and statewide capacity constraints regarding both COVID-19 vaccine administration and supply, distribution of vaccines has been painfully slow and disorganized, with success varying widely by state. On day one of his presidency, President Joe Biden signed numerous executive orders to improve the capacity of the nation’s health care systems to combat COVID-19, with the aim of vaccinating 100 million Americans during his first 100 days in office. Notably, a comprehensive strategy to address the destructive effects of the pandemic will require ensuring that the needs of LGBTQ people are integrated throughout the federal response.
The coronavirus poses unique health risks for LGBTQ communities
LGBTQ people are at greater risk of suffering severe illness from COVID-19 due to experiencing, at higher rates than heterosexual and cisgender people, chronic health conditions that compromise their immune systems. As of 2017, an estimated 65 percent of LGBTQ adults had underlying preexisting conditions such as diabetes, heart disease, or HIV, meaning they were immunocompromised; such people face increased risk of severe illness if they contract COVID-19. Additionally, people who have asthma or who smoke have respiratory systems that may be more vulnerable to serious illness from COVID-19. CAP analysis of data from the 2019 Behavioral Risk Factor Surveillance System reveals that 49 percent of LGBTQ adults smoke every day or some days, compared with 39 percent of non-LGBTQ adults, while 20 percent of LGBTQ adults have been informed they have asthma compared with 14 percent of non-LGBTQ adults. Unfortunately, the federal government currently does not collect data on LGBTQ people who have contracted COVID-19, and only a handful of states are even attempting to track this information.
Discrimination and cost continue to pose significant barriers to medical care for LGBTQ people, particularly during a pandemic that has jeopardized the employment and economic stability of millions of Americans. June 2020 nationally representative data from a 2020 CAP survey* illustrate how cost and discrimination continue to deter LGBTQ communities from seeking care. (see Figure 1)
Although the Affordable Care Act (ACA) increased access to insurance, LGBTQ people still face disparities in acquiring health insurance and are more likely to be uninsured than non-LGBTQ people. Testing and treatment for COVID-19 are meant to be free, but widespread failure to effectively communicate this, as well as holes in the various COVID-19 relief laws Congress has passed, mean that some patients still face exorbitant bills related to testing and treatment. These deficiencies may prompt people to forgo testing or treatment, jeopardizing their own health and the health of others and hindering detection of infection and identification of paths of transmission. States that have adopted Medicaid expansion maintain lower uninsured rates for their residents than states that have failed to do so and will be better poised to address the pandemic’s impacts.
These barriers and disparities in cost and insurance rates, in addition to discrimination, may help explain why recent data on the pandemic indicate that 38 percent of LGBTQ households “have been unable to get medical care or delayed getting medical care for a serious problem,” compared with 19 percent of non-LGBTQ households. Notably, social determinants of health—including persistent segregation and structural and environmental racism, as well as systemic racism—exacerbate the likelihood of LGBTQ people of color being disproportionately affected by COVID-19, especially Black or African American, Hispanic or Latino, and American Indian or Alaska Native communities.
Regrettably, the ability of LGBTQ people to access health care was repeatedly damaged by the Trump administration’s numerous attempts to explicitly strip comprehensive nondiscrimination protections from beneficiaries of federally funded services based on sexual orientation and gender identity (SOGI) and remove requirements to treat same-sex marriage equally, as well as efforts to eliminate LGBTQ nondiscrimination protections established by the ACA.
Recommendations to provide COVID-19 relief to LGBTQ communities
Mitigating the pandemic’s detrimental impact on the lives of LGBTQ people will require a strategically coordinated effort to implement policies in the areas of public health and health care, among others. Upon entering office, President Joe Biden immediately signed executive orders to protect LGBTQ people from discrimination; advance equity for underserved communities, including LGBTQ people; and establish a COVID-19 Health Equity Task Force as part of efforts to mobilize a coordinated and effective response to the COVID-19 pandemic both generally and specifically as it relates to data collection. These executive orders offer mechanisms through which a new administration can demonstrate its commitment to nondiscrimination and equity by integrating targeted assistance for LGBTQ people, particularly LGBTQ communities of color, throughout the federal response to this deadly pandemic.
Recommendations for state and local governments include the following:
- Ensure that COVID-19 testing and vaccinations—and appointments to receive the vaccination—are free and do not require ID, which can exacerbate accessibility inequities for vulnerable populations, including LGBTQ people, and deploy an informational campaign to ensure the public is aware of these facts.
- Explicitly include LGBTQ communities in the vaccine distribution plan and accompanying communication strategies to provide LGBTQ communities with information about accessing testing, vaccines, and their right to receive services free from discrimination under the law.
- Partner with LGBTQ community-based organizations to ensure that the rollout plan includes an outreach campaign with LGBTQ-specific messaging and education materials delivered by trusted messengers.
- Ensure that materials and outreach engagement address concerns and dispel distrust born of historical and ongoing mistreatment and abuse of LGBTQ people in health care settings, particularly among Black LGBTQ communities.
Recommendations for executive agencies and the White House include the following:
- Executive agencies should:
- Revise existing COVID-19 laboratory data guidance from the Department of Health and Human Services (HHS) to require data collection and reporting on SOGI in COVID-19 testing and vaccination in a manner that protects privacy and confidentiality and remains voluntary for individuals.
- Restore nondiscrimination protections based on SOGI among service providers, grantees, and contractors that receive federal funding through HHS.
- Ensure that HHS’ Office for Civil Rights enforces the ACA’s statutory nondiscrimination protections in a manner that is consistent with the U.S. Supreme Court’s decision in Bostock v. Clayton County prohibiting discrimination based on SOGI.
- Incentivize Medicaid expansion in states that have failed to implement it, as expansion has meaningfully improved the ability of low-income LGBTQ people to access health insurance.
- Issue guidance to protect vulnerable populations from discrimination in vaccine distribution to ensure that all people—regardless of sexual orientation, gender identity, race, immigration status, or criminal record—are able to access the vaccine when it is available to them. Executive agencies should also provide guidance on releasing incarcerated people, who are at high risk of contracting COVID-19, especially people living with HIV.
- Immediately conduct an audit of the current immigration detention population to release those at heightened risk of experiencing serious health consequences if they contract the coronavirus, as well as vulnerable populations—including LGBTQ people and people living with HIV—and others for whom detention is not strictly necessary.
- The White House should work with Congress to expand paid sick leave and paid family and medical leave protections to include chosen-family caregiving relationships.
Recommendations for all levels of government include the following:
- Ensure that trusted providers, such as LGBTQ-identified community health centers, and evidence-based family planning providers, such as Title X grantees, are well-resourced and actively incorporated into vaccine distribution plans.
- Expand access to care by prohibiting discrimination against LGBTQ patients and health service recipients, as well as eliminating discriminatory employment practices that undermine the availability of qualified health care workers, ensuring compliance with President Biden’s recent SOGI nondiscrimination executive order implementing the Bostock Supreme Court decision across the federal government. This includes providing LGBTQ communities with information about how the new executive order prohibits discrimination in health care and affects the rights of LGBTQ people.
The public health and economic crises created by the COVID-19 pandemic have magnified inequalities that have long existed in this country, particularly for LGBTQ people who are Black and Latino, women, and low-income. The Biden administration, as well as state and local governments, have a responsibility to deploy targeted policies for populations most in need, including LGBTQ people, their families, and their communities.
* Data are from a nationally representative survey of 1,528 LGBTQ+-identifying individuals, jointly conducted in June 2020 by the Center for American Progress and NORC at the University of Chicago.
Caroline Medina is a policy analyst for the LGBTQ Research and Communications Project at the Center for American Progress. Lindsay Mahowald is a research assistant for the LGBTQ Research and Communications Project.
To find the latest CAP resources on the coronavirus, visit our coronavirus resource page.