The Impact of the Affordable Care Act on LGBTQ Youth Experiencing Homelessness

Protestors call for Medicaid expansion in Nashville, Tennessee, on February 1, 2016.

Endnotes and citations are available in the PDF and Scribd versions.

See also: The Medicaid Program and LGBT Communities: Overview and Policy Recommendations by Kellan Baker, Ashe McGovern, Sharita Gruberg, and Andrew Cray

A major advancement of the Affordable Care Act, or ACA, is that Millennials entering the job market are now able to remain on their parents’ health insurance until age 26. This is not an option, however, for the many lesbian, gay, bisexual, transgender, and queer, or LGBTQ, Millennials who have left or been forced to leave their homes because of family rejection related to their sexual orientation, gender identity, or gender expression. This issue brief provides an overview of the other ways in which the ACA—especially the expansion of state Medicaid programs—helps LGBTQ young people without homes gain access to the health care they need.

LGBTQ youth are at higher risk of experiencing homelessness

Between 5 percent and 7 percent of youth in the U.S. general population identify as LGBTQ, while best estimates for the share of the out-of-home youth population that identifies as LGBTQ are between 9 percent and 45 percent. For LGBTQ young people, family rejection, harassment in schools, and inadequate support through the child welfare system contribute to these high homelessness rates. LGBTQ youth are also less likely than non-LGBTQ youth to have access to familial support, including financial support, so they are much more likely to engage in underground economies to meet their basic survival needs. Panhandling, selling drugs, and survival sex place them at higher risk of serious health concerns such as depression, suicidality, HIV infection, and drug addiction in addition to exposing them to frequent physical and sexual violence. A 2010 study of homeless youth in Hollywood, for instance, found that LGBTQ youth were three times as likely to have been sexually assaulted or raped than other youth experiencing homelessness.

The ACA can help more LGBTQ youth experiencing homelessness access health insurance and health care

While specific data on health insurance coverage for LGBTQ youth experiencing homelessness are unavailable, people without homes are generally uninsured at higher rates compared with the general population. The ACA addresses the problem of uninsurance among the homeless population in part by expanding eligibility for Medicaid, the federally supported coverage program that provides access to health care services for low-income individuals. Prior to the ACA’s passage, Medicaid eligibility was limited to low-income individuals in a handful of categories such as people with a disability, pregnant people, and people with dependent children. Childless adults without a disability could not qualify for Medicaid coverage in most states, no matter how low their incomes were. These narrow eligibility requirements excluded many people in need of assistance, including many LGBTQ young adults.

The ACA originally required that state Medicaid programs cover all individuals earning up to 138 percent of the federal poverty level, or FPL. When the U.S. Supreme Court considered the constitutionality of the ACA in June 2012, however, it ruled that the federal government cannot compel states to expand Medicaid, leaving the decision of whether to expand the program to governors and state legislatures. As of August 2016, 31 states and the District of Columbia have expanded their programs to cover all individuals with incomes up to 138 percent of the FPL, including childless adults. In 2016, the FPL stands at $11,880 per year for an individual and $24,300 per year for a family of four. Closing the coverage gap through Medicaid expansion in every state is a critical priority to ensure that low-income people—including LGBTQ young adults—are able to access health coverage and care.

In addition to Medicaid expansion, LGBTQ youth who are experiencing or are at risk of homelessness may be eligible for other assistance to gain coverage under the ACA.

Low-income LGBTQ minors are eligible for Medicaid in all states

Under the ACA, youth younger than age 19 with an annual income of less than 138 percent of the FPL may be eligible for Medicaid coverage in all states. The correlation between homelessness and poverty means that most homeless youth, including homeless LGBTQ youth, are likely to qualify for Medicaid coverage under this provision.

Youth younger than age 19 are eligible for health coverage at higher income levels based on limits set by each state. As of June 2016, all 50 states and the District of Columbia offer coverage through Medicaid or through another program called the Children’s Health Insurance Program, or CHIP, for income levels up to 175 percent of the FPL or higher. Some of these states require parental approval in order to apply, which may be prohibitive for LGBTQ youth experiencing homelessness.

LGBTQ youth who age out of the foster care system are eligible for Medicaid

Children in foster care are eligible for health coverage under Medicaid in all states. Under the ACA, young adults aging out of the foster care system can access Medicaid in the state in which they received foster care until they reach age 26. LGBTQ youth are overrepresented in the foster care population. One study estimates, for instance, that there are up to twice as many LGBTQ youth living in foster care as LGBTQ youth living outside of foster care in Los Angeles. Since many people without homes are former foster youth, the ACA will help ensure access to health coverage and health care for many LGBTQ youth experiencing homelessness.

It is important to note that states are not required to make Medicaid coverage portable from state to state. Thus, former foster youth previously enrolled in Medicaid in a different state may need to reapply in their new state of residence, and states are not required to cover youth who aged out of foster care in a different state.

Some LGBTQ youth experiencing or at risk of homelessness may be eligible for financial assistance to purchase insurance

Youth who are not eligible for Medicaid or CHIP can obtain financial assistance to buy coverage through HealthCare.gov or a state-based health insurance marketplace if their household income is between 100 percent and 400 percent of the FPL. In 2016, this ranges from $11,880 to $47,520 for an individual.

Without Medicaid expansion, the ACA cannot offer financial assistance to help people with incomes below 100 percent of the FPL access health insurance coverage. Because the 19 states that have not adopted the Medicaid expansion also have comparatively larger populations of communities of color and higher rates of poverty, their decisions to not expand Medicaid disproportionately affect LGBTQ youth of color and LGBTQ youth who cannot otherwise afford insurance.

4 things to know about applying or helping someone apply for Medicaid

1. For homeless youth, it may be easiest to apply for Medicaid coverage over the phone by calling 1-800-318-2596 (TTY: 1-855-889-4325) or using a paper application in order to receive assistance, rather than applying online.

2. Individuals without a permanent address can use an enrollment assister’s, trusted friend’s, or service provider’s address to apply for coverage.

3. There are no enrollment deadlines for Medicaid or CHIP, meaning that individuals can apply and be determined eligible for coverage at any time throughout the year.

4. The ACA prohibits discrimination against LGBTQ people seeking health insurance coverage or health care from programs or providers that receive federal funding, including state Medicaid programs, hospitals, health insurance marketplaces, and programs providing services to out-of-home youth. Specifically, ACA Section 1557 prohibits discrimination on the basis of sex, including gender identity and sex-based stereotypes related to sexual orientation, such as the expectation that men should only seek romantic relationships with women, and vice versa. Any LGBTQ person who experiences discrimination can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by visiting www.hhs.gov/ocr.

Conclusion

The ACA has created many new opportunities for LGBTQ youth experiencing homelessness to obtain health coverage and health care. State governments can help address the remaining gaps in coverage by extending Medicaid eligibility to former foster youth who were enrolled in Medicaid through age 18 in another state. In addition, Medicaid expansion in all states is a critical component of assisting all people who need financial help to afford health coverage and health care, including homeless LGBTQ young adults.

Shabab Ahmed Mirza is a Research Assistant for the LGBT Research and Communications Project at the Center for American Progress. Kellan Baker is a Senior Fellow with the LGBT Research and Communications Project at the Center.