The Affordable Care Act, or ACA, has helped more than 20 million people get new health insurance coverage. Millions more are benefitting from the ACA’s bans on coverage denials because of pre-existing conditions, unaffordable prices for bare-bones coverage, and discrimination in coverage and health care.
Lesbian, gay, bisexual, and transgender, or LGBT, communities have often experienced high rates of uninsurance and barriers to coverage and care, such as discrimination on the basis of gender identity and sexual orientation. A new study by the Center for American Progress, or CAP, finds that 15 percent of LGBT Americans across all income ranges are uninsured in 2017, compared to 7 percent of non-LGBT Americans.
The ACA is closing this gap for those who most need financial help to afford coverage. In 2013, before the ACA’s coverage reforms came into effect, 1 in 3 LGBT people making less than $45,000 per year (34 percent) were uninsured. Just one year later, in 2014, uninsurance for this group had dropped by one-quarter to 1 in 4 (26 percent), and by 2017, CAP’s study finds that it was around 1 in 5 (22 percent). Conservative proposals to repeal and replace the ACA—such as the American Health Care Act, or AHCA—would undo these gains and hurt LGBT people, their families, and their neighbors. The path to a stronger, healthier America for all lies not in depriving millions of Americans of the benefits of coverage but in protecting and expanding on the gains of the ACA.
To conduct this study, CAP surveyed 1,864 individuals about their experiences with health insurance and health care. Among the respondents, 857 identified as lesbian, gay, bisexual, and/or transgender, while 1,007 identified as heterosexual and cisgender/nontransgender. Respondents came from all income ranges and are diverse across factors such as race, ethnicity, education, geography, disability status, and age. The survey was fielded online in English in January 2017 to coincide with the fourth open enrollment period through the health insurance marketplaces and the beginning of the first full year of federal rules that specifically protect LGBT people from discrimination in health insurance coverage and health care. The data are nationally representative and weighted according to U.S. population characteristics. All reported findings are statistically significant unless otherwise indicated.
Overall, LGBT people are more than twice as likely to be uninsured as non-LGBT people: 15 percent of LGBT respondents are uninsured, compared to 7 percent of non-LGBT respondents. This finding aligns with recent reports that the overall uninsurance rate for all Americans is 8.6 percent. Uninsurance is highest among transgender individuals: 25 percent of transgender respondents are uninsured, compared to 8 percent of cisgender respondents. Among sexual minority respondents, bisexual individuals have a higher level of uninsurance (19 percent) than gay men (6 percent) and lesbians (4 percent). Individuals who identify as queer and asexual also have high rates of uninsurance (17 percent and 50 percent, respectively), though small sample sizes did not allow statistical testing of these coverage gaps.
Among LGBT respondents, people living in the South are significantly more likely than people living in the Northeast to not have coverage (21 percent versus 9 percent uninsured, respectively). This difference is much smaller and not statistically significant for non-LGBT respondents in these regions (11 percent versus 8 percent), suggesting that the hostile legal and social climates experienced by LGBT communities in the South—in addition to the lack of Medicaid expansion in this region—may be contributing to higher rates of uninsurance for LGBT people.
Among all respondents, African Americans are significantly more likely than white Americans to be uninsured (17 percent versus 5 percent). Latinx individuals and individuals who reported two or more racial identities also have higher rates of uninsurance (14 percent and 10 percent), though these differences are not statistically significant. Among LGBT respondents, there are no significant differences in coverage by race or ethnicity: 14 percent of white respondents, 14 percent of African Americans, 33 percent of Latinx individuals, and 3 percent of individuals who reported two or more racial identities are uninsured.
Impact of the American Health Care Act on LGBT communities
Features of the ACA, such as income-based tax credits, to help make coverage more affordable and the expansion of Medicaid provide significant benefits for lower-income communities, including LGBT people who are struggling economically. By contrast, the American Health Care Act—the new health care proposal that is up for a vote in the House of Representatives on the anniversary of the ACA’s passage—would undermine these benefits by stripping coverage from 24 million people and raising costs for low-income people, seniors, and other vulnerable Americans.
Overall, LGBT people—especially transgender people, LGBT people of color, and LGBT parents—are significantly more likely than non-LGBT people to live in poverty. Among LGBT respondents in the CAP survey, 34 percent live in households earning less than $35,000 per year. Many more are in precarious financial circumstances: In general, LGBT respondents are significantly less likely than non-LGBT respondents to be confident of being able to afford regular medical costs, such as doctor visits and prescription medications (81 percent versus 90 percent); less likely to be confident of being able to afford major medical costs, such as hospitalization (72 percent versus 82 percent); and more likely to have medical bills that they cannot pay (19 percent versus 12 percent).
Insurance provides a critical shield against these concerns: Regardless of income, insured LGBT respondents are more than twice as likely to be confident they can afford regular medical costs (90 percent of the insured versus 38 percent of the uninsured) and more than three times as likely to be confident they can afford major medical costs (82 percent of the insured versus 24 percent of the uninsured).
The broadening of affordable insurance options under the ACA through both traditional and expansion Medicaid and the health insurance marketplaces is essential to the health and financial well-being of LGBT Americans. For instance, among LGBT respondents who explored their coverage options in the past year, 36 percent found they are eligible for Medicaid, and three-quarters of those who are eligible subsequently enrolled. Among all LGBT respondents, 18 percent have Medicaid coverage, and among those with incomes less than 250 percent of the federal poverty level, or FPL, the proportion rises to 40 percent.* By comparison, Medicaid covers 8 percent of all non-LGBT respondents and 22 percent of non-LGBT respondents with incomes under 250 percent of the FPL. Using the most recent estimate of the size of the LGBT population, approximately 1.8 million LGBT adults have Medicaid coverage.
Of LGBT respondents who sought coverage through a health insurance marketplace in the past year and were not eligible for Medicaid, more than half (51 percent) learned they are eligible for advance premium tax credits that make their plans more affordable. Marketplace coverage options are particularly important for same-sex couples in light of continuing discrimination by employers on the basis of sexual orientation: Although lesbian, gay, and bisexual, or LGB, and heterosexual respondents are equally likely to have coverage through their own employer (38 percent and 39 percent, respectively), LGB individuals are less than half as likely as heterosexual individuals to have access to coverage through a spouse or partner’s employer (7 percent versus 18 percent).
The future of America’s health
A great deal is at stake for LGBT people—and all Americans—in the current debate about the future of the Affordable Care Act. The ACA’s reforms have helped expand the availability of health insurance coverage and are strengthening the links between affordable coverage and high-quality care. By contrast, the AHCA’s proposal to slash Medicaid funding and cut financial assistance that helps lower-income people afford coverage has serious consequences for millions of Americans, including LGBT people and their families. The bill would prevent the uninsured from gaining coverage and cause many of those who have gained coverage under the ACA to lose it. To truly improve the health of all Americans, the nation should move forward with continuing to build on the foundation laid by the ACA rather than allowing the clock to be rolled back to the era of high costs, poor quality, and rampant uninsurance.
Kellan Baker is a Senior Fellow with the LGBT Research and Communications Project at the Center for American Progress. Laura E. Durso is the Vice President of the Center’s LGBT Research and Communications Project.
* Note: Precise income data to calculate the income-to-poverty ratio were not available through the current survey. In the survey data, respondents’ annual household income is given in ranges—with smaller increments of $2,500 to $5,000 for lower-income respondents and larger increments of $25,000 to $50,000 for high-income respondents. To assess income relative to the FPL, the authors assigned each respondent income at the midpoint of their income range—for example, those in the range of $5,000 to $7,499 are assigned income of $6,250—and then divided midpoint income by the poverty guideline corresponding to the respondent’s household size.