As the United States grapples with the spread of the novel coronavirus, which causes the disease COVID-19, advocates and service providers across the country are struggling to support LGBTQ people in their communities. Times of crisis magnify the country’s systemic inequality, and the current crisis is no exception. Moreover, the people living at the intersection of multiple identities that have been historically excluded and discriminated against will be, and already are, the hardest hit.
The coronavirus crisis threatens to compound the disparities that LGBTQ people already experience in health care, as well as the community’s high rates of poverty. The LGBTQ population is both particularly at risk in the current crisis and woefully underserved. A recent letter from more than 100 organizations highlighted the ways in which widespread health care discrimination puts LGBTQ people at particular risk of potentially deadly outcomes from the coronavirus. For example, a large share of LGBTQ people have compromised immune systems. Addressing barriers to health care for LGBTQ people, as well as ensuring that financial support and services reach LGBTQ people and their families, is crucial to mitigating the pandemic’s impact on the nation’s health and well-being.
Why the coronavirus has the potential to be more dangerous for LGBTQ people
LGBTQ people experience high rates of chronic conditions that compromise their immune systems and heighten their vulnerability to contracting COVID-19. An estimated 65 percent of LGBTQ adults have pre-existing conditions such as diabetes, asthma, heart disease, or HIV. According to the Centers for Disease Control and Prevention (CDC), these conditions put them at high risk for severe illness from COVID-19. Smoking is another factor that can cause people to be immunocompromised. And according to an aggregate sample of adults from the 2016 Behavioral Risk Factor Surveillance System, smoking rates for LGB adults were 49 percent higher than rates for non-LGB adults. Rates were 42 percent higher for transgender adults than for cisgender adults. Studies show that many LGBTQ people turn to smoking as a method to cope with the stigma and discrimination that they face.
LGBTQ people are also more likely to be uninsured. The Affordable Care Act (ACA) helped lower uninsurance rates among low- and middle-income LGBTQ adults by 35 percent between 2013 and 2017, but LGBTQ adults are still more than twice as likely to be uninsured than non-LGBTQ adults. While 1.8 million LGBTQ adults have Medicaid coverage, the failure of 14 states to expand coverage contributes to uninsurance rates. And although most Americans get health insurance coverage through their employer, the lack of explicit federal nondiscrimination workplace protections for LGBTQ people puts them at risk of losing their insurance if they are fired because of their sexual orientation or gender identity. And discriminatory hiring practices put LGBTQ workers at risk of not being able to secure employment and benefits in the first place. A nationally representative survey conducted by the Center for American Progress found that LGB people were less than half as likely to have access to insurance coverage through a spouse’s or partner’s employer than heterosexual individuals. The serious risk that COVID-19 poses for LGBTQ people makes the ability to access quality and affordable health coverage even more important.
Discrimination prevents LGBTQ people from accessing needed medical care
Even when LGBTQ people have insurance coverage, discrimination can prevent them from accessing medical care. A growing number of courts are interpreting the ACA’s prohibition on sex discrimination to prohibit discrimination based on sexual orientation and gender identity in federally funded health programs; however, the U.S. Department of Health and Human Services (HHS) is currently finalizing a rule that would remove explicit protections for LGBTQ patients. A nationally representative survey commissioned by CAP found that 1 in 4 LGBTQ people reported experiencing discrimination in the year prior, while 8 percent of lesbian, gay, and bisexual adults and 29 percent of transgender adults reported that a health care provider refused to see them because of their actual or perceived sexual orientation or gender identity. LGBTQ people who experienced any form of discrimination were nearly seven times more likely to report avoiding a visit to a doctor’s office to avoid discrimination. No one should be denied medical care because of their sexual orientation or gender identity, particularly not during a pandemic.
Millions of LGBTQ people experiencing homelessness and in custody are unable to protect themselves
LGBTQ youth and young adults are 120 percent more likely to experience homelessness than their non-LGBTQ peers, and transgender and nonbinary adults are more likely to be unsheltered than cisgender people experiencing homelessness. LGB people are incarcerated at three times the rate of the general population, and nearly 1 in 10 Black transgender respondents to the U.S. Transgender Survey reported being incarcerated in the previous year. Many LGBTQ people are among the more than 35,000 people held in immigration detention every day. Implementing social distancing measures can be impossible in shelters and detention facilities, and people experiencing homelessness and people in custody lack adequate access to protective gear and hygiene resources to safeguard themselves. Immigration Equality recently filed a complaint with the U.S. Department of Homeland Security on behalf of six LGBTQ asylum seekers who are living with HIV in immigration detention. The complaint points out that contagious diseases such as COVID-19 spread quickly in confinement settings where people are housed in close quarters, that these facilities are unhygienic, and that people with compromised immune systems are at particularly high risk.
The pandemic will further threaten the economic security of LGBTQ people
The coronavirus pandemic has created an economic crisis as well as a public health crisis. Low-income communities will be among the hardest hit by the upcoming economic downturn, with people who are already struggling to make ends meet forced into even more dire circumstances. More than 1 in 3 LGBTQ respondents to CAP’s nationally representative survey reported living in households that earned less than $35,000 per year. LGBTQ people and their families are also more likely to rely on federal benefits such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, subsidized housing assistance, and unemployment insurance, with LGBTQ people of color, transgender people, and LGBTQ people with disabilities reporting even higher benefits usage rates. LGBTQ people also experience high levels of housing insecurity and homelessness, particularly LGBTQ youth, transgender people, and older LGBTQ adults.
LGBTQ people and their families already need support, and the current crisis will increase these needs. Unfortunately, the Trump administration has taken numerous steps to undermine access to critical supports and services for LGBTQ people, including ending the enforcement of prohibitions on discrimination based on sexual orientation and gender identity for service providers that receive funding from HHS and proposing rules to eliminate safeguards for LGBTQ people and others seeking services from faith-based providers.
Many LGBTQ people rely on so-called chosen family—individuals who form close bonds akin to those traditionally thought to occur in relationships with blood or legal ties—for support and caretaking. CAP data show that 42 percent of LGBT adults in the United States report having taken time off work to care for a friend or chosen family member with a health-related need, while 31 percent of non-LGBT individuals reported doing so. In order to ensure that LGBTQ people are able to care for their loved ones and receive the care that they need, it is critical that paid sick leave and paid family and medical leave protections extend to caregiving relationships that are akin to those for blood or legal relatives. Unfortunately, according to the Bureau of Labor Statistics, only 18 percent of private sector workers have access to paid family leave. In addition, those caretaking for chosen family often must rely on other kinds of paid leave if they have it, such as paid sick leave or personal leave—but many low-wage workers lack these options as well.
Ensuring federal and state relief reaches those in need
As of the date of publication, Congress has enacted three laws in response to the pandemic: The Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act, and the Coronavirus Aid, Relief, and Economic Security (CARES) Act.
These laws are an important start to providing LGBTQ people and their families with needed assistance. Workers covered by the Families First Coronavirus Response Act will be able to access up to two weeks of emergency paid sick leave if they are ill, quarantined, caring for an individual who is ill or quarantined, or caring for a child whose school or place of care has closed due to the pandemic. Parents who are covered by the law can also take an additional 12 weeks of emergency child care leave—with 10 of the weeks paid—to care for a child whose school or place of care has closed. Unfortunately, an estimated 61 million to 96 million private sector employees, and more than 2 million federal workers, may not be guaranteed coverage by the emergency paid leave protections due to exemptions in the law and U.S. Department of Labor implementation rules. The exemptions mean that large businesses with 500 or more employees are excluded entirely; that employers can decide to exclude employees who are health care providers and emergency responders; that the Office of Management and Budget may decide to exclude federal workers from emergency paid sick leave; and that small businesses can self-determine that they are exempt from providing any paid child care leave protections under the law. These protections should be fixed to cover these excluded workers and should be expanded to include paid medical and caregiving leave—one with a broad definition of family that reflects the reality of caretaking relationships and chosen family.
The CARES Act also provides needed relief, including an additional $600 per week in unemployment benefits and an extension of benefits for up to 13 additional weeks, eligibility for nonprofits to access Small Business Administration (SBA) loans to make sure organizations can continue to pay their staff and keep their doors open, increases in food assistance, and direct cash assistance. Under the Paycheck Protection Program, qualifying organizations can obtain SBA loans for their payroll, rent, and utilities; these loans will be forgiven if they maintain payroll and staffing for two months. Most individuals earning less than $75,000 will receive a one-time cash payment of $1,200, while most married couples earning less than $150,000 will receive $2,400 and families will receive $500 per child. However, this cash assistance is tied to a Social Security number, which excludes many LGBTQ immigrants and LGBTQ people in families with differing immigration statuses. And unemployment benefits are out of reach for LGBTQ people pushed into underground economies.
The CARES Act also provides needed funding increases to programs, including $100 billion in grants to cover unreimbursed health care-related expenses or lost revenues because of the crisis; $425 million for the Substance Abuse and Mental Health Services Administration to increase access to mental health services; $955 million for the Administration for Community Living to support nutrition programs and community-based services for seniors and individuals with disabilities; and $90 million for the Ryan White HIV/AIDS Program. Yet more funding is needed to adequately support these critical programs. Also, HHS has announced that it will not enforce nondiscrimination requirements for grant recipients, which jeopardizes access to services funded by the law for otherwise-eligible LGBTQ people and their families.
The response to the coronavirus must consider the needs of LGBTQ people
In light of the health disparities, discrimination, and inequality that LGBTQ people face, efforts to combat the coronavirus should be tailored to meet the needs of LGBTQ communities.
Health care needs:
- All levels of government must remove arbitrary barriers to care by expanding access to care and prohibiting discrimination against LGBTQ patients and service recipients as well as people seeking shelter. They must also not allow discriminatory employment practices to undermine the availability of qualified health care workers.
- All levels of government should ensure that trusted providers, such as LGBTQ-identified health centers, and evidence-based family planning providers, such as Title X grantees, are well-resourced. They should also partner with LGBTQ community-based organizations to ensure that information about the new laws is coming from trusted sources.
- State and local governments should explicitly state in stay-at-home orders that contraception access, abortion, HIV testing, and syringe services programs are essential health services that will continue.
- The federal government should reopen the federal insurance ACA marketplace.
- The federal government should freeze rulemaking that is not directly related to the COVID-19 response and cease implementation of rules that undermine nondiscrimination protections and access to federally funded programs.
- State and local governments should not require ID for accessing coronavirus testing.
- State governments that have not already done so should expand Medicaid.
Homelessness services:
- Lawmakers should prioritize permanent housing placements for people experiencing homelessness.
- Local governments should ensure that a portion of the CARES Act’s Emergency Solutions Grants goes directly to homelessness providers serving youth.
- Local governments should not clear encampments but instead should focus on providing the option of individual housing solutions to people experiencing unsheltered homelessness.
Federal benefits and assistance:
- State governments should eliminate work requirements for federal benefits.
- Future federal funding should increase and expand SNAP benefits.
- State and local governments should suspend evictions and provide rental assistance for the duration of the crisis.
- Congress should expand emergency paid leave protections to ensure that all businesses and workers are covered and have access to paid medical and caregiving leave with a broad definition of family that reflects modern caregiving relationships.
Immigration policy:
Custodial settings:
- Governments should release as many people as possible from custody, including immigration detention, and partner with community organizations to ensure support for people who are released. Governments should also ensure that facilities uphold the CDC’s safety and health COVID-prevention protocols, including free access to hygiene products.
The inequality experienced by LGBTQ communities puts them at risk of being disproportionately harmed by the COVID-19 pandemic. Furthermore, people being unable to access care during a contagious disease pandemic is a risk factor for everyone. In order to effectively combat the crisis, it is critical that all levels of government work to ensure that LGBTQ people and their families are not left behind by responses to the pandemic.
Sharita Gruberg is the director of policy for the LGBTQ Research and Communications Project at the Center for American Progress.
To find the latest CAP resources on the coronavirus, visit our coronavirus resource page.