In 1985, the groundbreaking “Report of the Secretary’s Task Force on Black and Minority Health” called the “tragic dilemma” of health disparities among minority communities “an affront to both our ideals and the ongoing genius of American medicine.” More than 25 years later, these disparities persist, even as recognition of their reach and efforts to eliminate them have grown.
According to the recently introduced Health Equity and Accountability Act, “Health disparities are a function of not only access to health care, but also the social determinants of health—including the environment, the physical structure of communities, nutrition and food options, educational attainment, employment, race, ethnicity, sex, geography, language preference, immigrant or citizenship status, sexual orientation, gender identity, socioeconomic status, or disability status—that directly and indirectly affect the health, health care, and wellness of individuals and communities.”
Clearly, race and ethnicity matter in health. So do gender, poverty, and ability. So too do sexual orientation, gender identity, and other characteristics linked to discrimination or exclusion. An African American baby is still twice as likely as a white baby to die before her first birthday. In the richest country in the world, one person dies every 12 minutes from lack of health insurance. Despite advances in HIV prevention and treatment, gay and bisexual men are still disproportionately likely to become infected with HIV and to die from AIDS. In America today, social and economic disadvantages kill.
Health disparities such as these do not occur in a vacuum. Like poverty, they feed off established social and economic structures that determine the distribution of power and resources. What’s worse, inequality turns diversity into disparity. For someone who belongs to multiple communities that experience health disparities, these disparities do not simply add up: They multiply.
Take the case of gay and transgender communities of color. Despite all the noise about our supposedly “postracial” America, discrimination still haunts anyone whose skin color doesn’t match the white faces that dominate boardrooms, statehouses, and the halls of Congress. Similarly, while things have improved for most gay and transgender people in the United States since the stigma, silence, and arrests that characterized the era before the rise of the gay rights movement, gay and transgender Americans still face widespread discrimination in relationship recognition, employment, and access to health insurance and health care.
Discrimination limits opportunity and choice. As a result, gay and transgender people of color may be more likely than the general population—and more likely than either white gay and transgender people, or straight and nontransgender people of color—to be less healthy and experience greater disparities in health care access. They are more likely to live in poverty, to have trouble seeing a doctor when they need to, and to live in environments where the surgeon general’s goal of making the healthy choice the easy choice remains an unfulfilled promise. For too many Americans, each additional “disparity factor,” from having a disability to being a woman to living in a rural area, magnifies the health gap.
From disparity to equity
How can we break the cycle of disparities breeding disparities? One step we can take is changing our lens from health disparities—a focus on what has gone wrong—to health equity – a focus on where we want to be. The U.S. Office of Minority Health defines health equity as the attainment of the highest level of health for all people. Achieving it requires not only valuing everyone equally but also taking concrete steps to address inequality, close disparities, and build a healthier society.
The Health Equity and Accountability Act of 2011 is such a step. This legislation, introduced in the House on September 15, is sponsored by the Congressional Tri-Caucus (the Hispanic, Black, and Asian and Pacific American congressional caucuses) and was drafted in consultation with a coalition of more than 30 health and social justice groups, including the Center for American Progress Action Fund.
The Health Equity and Accountability Act is the most comprehensive legislation ever to recognize that gay and transgender health disparities cannot be addressed in isolation from other health disparities, including disparities affecting people with disabilities, communities of color, women, and people in families with mixed immigration statuses.
Areas of intersection between sexual orientation, gender identity, and other disparity factors reflected in the act include steps to address mental health concerns linked to minority stress, such as depression, anxiety, and suicide; higher rates of smoking and other substance use; and greater risk of exposure to sexually transmitted infections. Fear of mistreatment from health care providers who are not familiar with culturally competent care for different minority populations also prevents many gay and transgender people from accessing vital health services and compounds the seriousness of conditions such as heart disease, cancer, and diabetes. To help address this, the act’s definition of cultural competence specifically includes sexual orientation and gender identity.
Discrimination in recognition of diverse family structures is another area in which the experiences of many gay and transgender people, communities of color, and immigrant communities especially overlap. According to the American Community Survey, same-sex couples live in almost every county across the country. More than 1 million of these families—disproportionately black and Latina lesbians—are raising children. The act includes specific nondiscrimination protections for all families, as well as for gay and transgender individuals.
The full extent of the health disparities affecting gay and transgender people, particularly those who also belong to other minority communities, remains unknown. Because major public health surveys collecting data that can help identify racial and other disparities do not ask respondents about their sexual orientation and gender identity, gay and transgender people have been almost invisible in the national fight for health equity. In its strong call for better data collection on gay and transgender communities, the Health Equity and Accountability Act builds on this summer’s promise from the Department of Health and Human Services to begin including sexual orientation and gender identity questions on federally supported health surveys and eventually developing standards to guide the routine collection of high-quality data on the health of gay and transgender communities.
Winning a healthier future
Our nation’s goal of “winning the future” for everyone in America requires building a world in which complexity of identity is not reduced to multiplicity of risk. The Health Equity and Accountability Act is a vital step in this direction. Achieving health equity will require collecting more data, conducting more research, and dedicating more resources to understanding and fighting the health disparities that affect disadvantaged communities, including gay and transgender people. It is an uphill battle—but it is a battle that we as a nation cannot afford to ignore.
Kellan Baker is a Health Policy Analyst with the LGBT Research and Communications Project at American Progress.