Andrew Bolibol, a PhD candidate in Harvard University’s Health Policy Program, highlights trends and gaps in health insurance coverage between LGBT and non-LGBT adults.
While health care among the lesbian, gay, bisexual, transgender (LGBT) community is an important conversation any time of year, June—Pride Month—puts a much-needed spotlight on reducing the coverage gap between LGBT and non-LGBT individuals.
In a study published in Health Affairs, Andrew Bolibol, a PhD candidate in Harvard University’s Health Policy Program, and colleagues explored trends in health care coverage and access for LGBT and non-LGBT adults from 2013 to 2019.
During this time frame, the main coverage provisions of the Affordable Care Act (ACA) went into effect in 2014, introducing affordable alternatives to employer-based insurance, and extending public insurance to all low-income individuals living in states that opted for Medicaid expansion.
Bolibol dives into his research on health insurance coverage and care access among LGBT adults, how the ACA and the legalization of same-sex marriage have played a role in these trends, and what policy changes are still needed to further bridge the coverage gap in this interview with The American Journal of Managed Care® (AJMC®).
AJMC: How did trends in health insurance coverage among LGBT adults change between 2013 and 2019, and what role did the ACA play in this?
Bolibol: I think one of the most prominent conclusions or takeaways from the paper is that we saw a rather stunning result in that, from pre-ACA, or rather the start of the provisions of the ACA taking effect, there was a large gap in health insurance coverage between LGBT folk and non-LGBT folk. By 2019, that gap actually closed entirely, and for partnered LGBT adults, they were slightly more likely to be covered by health insurance than their non-LGBT counterparts. And this wasn't a causal study, so we can't necessarily attribute it to any one thing, and I think it is a combination of policy changes that led to this decrease.
The ACA, in particular, had a couple avenues through which LGBT people gained substantial amounts of health insurance. One of those is prominently for more younger adults, which was the provision of dependent health insurance coverage up until age 26. And our sample did skew a little bit younger, so that could have played a role, as well as what you mentioned with Medicaid expansion for the states that opted for Medicaid expansion that got rid of the categorical eligibility requirement of having a dependent, so you can qualify based solely on income up to 138% of the federal poverty line. And then lastly, they built marketplaces, so that offered another avenue for others who are not eligible, say for Medicaid, to gain health insurance coverage. I think it's a combination of all those things, as well as some other aspects not related to the Affordable Care Act that really drove that change in the coverage gap.
AJMC: You also noted that LGBT adults were more likely to have difficulty accessing necessary medical care prior to the ACA. How has this changed since?
Bolibol: In the beginning of our study period, we also saw significant gaps in access to coverage. Things like having a primary care provider or seeing a usual provider, prescription medications, mental health visits, so on and so forth, kind of preventive services were at large. That was a significant gap at the beginning of the period. It closed quite a bit by the end of our study period, which is 2019. But there still is a significant disparity between LGBT adults and non-LGBT adults in being able to access and afford care. And that is still the case by the end of 2019. LGBT adults fare worse than their non-LGBT counterparts in accessing broad measures in terms of care.
AJMC: When the Supreme Court legalized same-sex marriage in 2015, how may this have contributed to the improved health insurance access among LGBT adults?
Bolibol: One of our subgroup analyses was LGBT individuals who are partnered and nonpartnered, and non-LGBT partnered and nonpartnered individuals. We surmised that obviously this is going to have a huge effect, because about 70% of Americans are covered by employer sponsored insurance. By extending that coverage through their spouse, we anticipated at the time that that probably would have some effect, although we can't necessarily say it's directly linked but have some implications.
It actually goes back to before Obergefell [v Hodges], which is the 2015 case legalizing same-sex marriage. And it was United States v Windsor, and that case overturned one provision of the Defense of Marriage Act. That provision that was overturned was defining marriage as between a man and a woman, and that was passed in the 90s. That was a big roadblock for a lot of LGBT folk in being able to access insurance coverage. So what that did is, in the states that had laws on the books legalizing same-sex marriage, those states were allowed to recognize same-sex marriage.
But it wasn't until the 2015 Supreme Court case where [same-sex] marriage was legalized across the United States. And that extended the federal tax exclusion benefits for health insurance to all LGBT folks who are in marriages across the United States. So, it's likely that it had quite a big effect. When we were looking at partnered vs nonpartnered LGBT folk, we saw the largest gains, in terms of health insurance coverage for partnered LGBT individuals, kind of indicating that the legalization of same-sex marriage probably did play a role in closing that insurance gap.
AJMC: Was this study able to look at data and trends regarding LGBT adults living states where same-sex marriage was legalized at the state level, prior to Obergefell v Hodges?
Bolibol: There's actually been some prior work done pre-ACA. There's a little bit of literature looking at how individuals in states that had legalized same-sex marriage fared compared to others in states that did not legalize same-sex marriage. They found small differences with those living in states that legalized same-sex marriage having slightly better [rates of] coverage of health insurance than those who did not. We didn't necessarily look at that, mainly because we focused on a couple of different areas. We wanted to focus on the fact that we're covering a time period where same-sex marriage was legalized across the United States. So, those provisions in terms of barriers to accessing care in states that previously did not have the same-sex marriage laws on the books were probably lowered significantly. There is some work done, but we just didn't focus on that in our study.
AJMC: Your study used data from the Health Reform Monitoring Survey to come to these findings. Did these survey results reveal any demographic differences at any point?
Bolibol: There's a couple points on that. We did run analyses for male vs female gender identities. And the results were pretty much the same across the genders. When we wanted to look at race and ethnicity, the problem was that we were pretty underpowered to detect a lot of differences already, because the size of the LGBT sample within our sample was not small, but it was relatively small, such that we couldn't really detect any differences.
What has been done in other literature is they collapse race and ethnicity variables to White vs non-White. I'm personally not a fan of that, and also not a fan of the fact that we had to collapse LGBT to one variable. That was more of the nature of how they asked the question and how they reported the data in the survey. But I think when we tried to collapse a race and ethnicity variable into something binary as White vs non-White, it obscures a lot of the heterogeneous difficulties that different individuals face depending on their race and ethnicity, so we didn't feel particularly comfortable doing that.
It's rather unfortunate that we weren't able to, because when we think about health disparities—not just LGBT, but any marginalized identity—there's a lot of intersectionality when it comes to the challenges and barriers faced, and race and ethnicity plays a massive role in that as well as being LGBT. So, besides like partnered vs nonpartnered—we consider that a demographic—and male vs female, we didn't really go much further, again, because we weren't powered to do so.
AJMC: Despite comparable insurance coverage rates by 2017-2019, LGBT adults were still more likely to have trouble paying medical bills, or go without medical care, prescription drugs, or mental health care compared with non-LGBT adults. Can you expand on what you found in these areas?
Bolibol: Again, the data kind of limited us because they didn't necessarily go further and asking what kind of cost barriers individuals faced. So, in our paper, we just hypothesized a few mechanisms through which we thought this could manifest itself. One of those being if LGBT folk in the marketplace differentially selected into high deductible health plans. We know from a pretty large body of research in economics that people respond in very atypical ways when they're faced with something like a high deductible health plan, not to mention that health insurance contracts in general are very complex and difficult to understand. So that can be driving a lot of why we're seeing these cost issues.
There's also the case of just the differential type of care that LGBT folks need, especially if you think about transgender individuals when they try to receive trans affirming care. Not only is it—depending on where you are—very difficult to obtain that care, but even coverage of that care and the cost of the care can be prohibitive.
Those are a couple of mechanisms, and I would be remiss if I didn't also mention the fact that racism and discrimination and bias most likely played a huge role. It might not be a monetary cost, if we think about something like a transaction costs for these individuals. Just those perceptions of discrimination can really drive access barriers or create barriers for people to just utilize the care despite the fact that they have health insurance coverage.
I think a really great body of future research as well is actually figuring out, when we say there are these cost barriers that people attribute [to] not being able to fill their prescription drugs or get the primary care provider, is it the monetary costs they're facing? Is that because they're on a high deductible health plan? Or is it because of the types of care that they need tend to be more expensive? So, for a lot of gay and bisexual men, access to pre-exposure prophylaxis (PrEP) and the ongoing court case that overturned the United States Preventive Services Task Force's ratings and determining that health plans must cover with zero cost sharing things like PrEP, that's under review. I think it's still being reviewed by the Fifth Circuit of Appeals. So when it comes to those issues, like PrEP can be very cost prohibitive if somebody has to pay out of pocket for the copay, and that's just something we weren't able to pick up in our study, unfortunately.
The data out there is getting better in terms of asking more detailed and nuanced questions. I think it just points to the fact that it's good to have representation in all of these things to actually know that we need to be asking these questions. Because, at face, just asking whether somebody's LGBT or not isn't necessarily going to paint the whole picture of what their health care and their health needs are.
AJMC: What do we know about differences in medical care for LGBT patients in Medicaid expansion vs nonexpansion states since 2014?
Bolibol: Also prior to our study, there was one specific study that looked at how Medicaid expansion affected health insurance coverage for LGBT adults finding that in Medicaid expansion states, it was significantly better than the nonexpansion states. I want to caveat that with the timeframe that we're in right now, in that Medicaid agencies differ across states, as we know, so they have some authority over what services they're allowed to provide.
If you follow the news, I think you'll find that in some states in particular—Florida being an example—Medicaid agencies are rolling back provisions for trans affirming care which creates a humongous barrier, not just in terms of being able to access trans affirming services that are very important for people's mental health and well being in general, but also the cost issue. So, if they wanted to find alternative forms of health insurance that would cover these things, it's most likely that they're not going to be able to, especially transgender individuals. I think [with] Florida also being a nonexpansion state, that individuals tend to fare better in the Medicaid expansion states.
We didn't particularly look at that because some work had been done prior to that. But, again, that heterogeneity of state Medicaid services makes it a little more difficult to say with certainty or with any kind of precision how care is affected. Because one state Medicaid agency might fully pay for trans affirming services while another might not, and obviously that would drive a huge disparity.
Even within the Medicaid expansion states, things aren't uniform. It can be very difficult on top of the fact that we don't really have an identifier for each person within the LGBT community, so we weren't able to differentiate between trans individuals vs lesbians vs gay men, bisexual men, so on and so forth, and not to mention the whole other host of identities that fall within the LGBTQ community. So, it's difficult to say much besides the fact that LGBT individuals tend to fare better in expansion states than they do in nonexpansion states.
AJMC: What policy recommendations can be made to further improve access to care for LGBT adults?
Bolibol: This is a great question, because it's somewhat related to what I was just talking about in the previous question. A lot of individuals access care through Medicaid. From this paper, we saw great improvements in health insurance coverage and it was primarily driven by private coverage of health insurance. Those plans tend to cover different services relative to, say, Medicaid. I think that the policy takeaway here is that, it's hard to say from our paper that there's like one singular thing because it wasn't necessarily a causal study, but I think this goes back to how Medicaid covers health care services specifically geared towards LGBT individuals or services that LGBT individuals tend to use disproportionately so, such as trans affirming services as well as things like PrEP that need to be covered. When we're limiting access or limiting the kinds of services that are covered by Medicaid, we're really recreating the problem of access, and the cost issue is the thing that comes up the most.
Medicaid is shown in a large body of research to be very great for people's mental health and their financial well being. And I think that's also going to be the case with LGBT individuals, because their care could potentially be more expensive than their non-LGBT counterparts. So I think the policy takeaway here is, we probably should be compelling Medicaid to be uniform in the services that they offer or cover for LGBT folk and also, in some sense, try to compel the states that have not expanded Medicaid to expand Medicaid. That's just a broad health policy takeaway; it's not necessarily related solely to LGBT individuals and how they fare. That would affect a lot of people. But I think that that provision in and of itself would do a lot in covering very low income individuals in these states who cannot move or they cannot access care, so they're really stuck in terms of their options.
In the private coverage area, I think there are still some gains to be made in that even as recent as 2020, in terms of companies offering health insurance benefits to same-sex couples as well as heterosexual couples, it was actually not even. There are still some companies that don't extend health insurance coverage to same-sex couples despite the fact that they have to, they are compelled to by the ACA. If they offer health insurance to married individuals, they have to extend it to same-sex couples because of the 2015 Supreme Court case. I think the fact that in 2020...that those provisions are still in place is limiting access for individuals who are legally married, whose marriage is recognized by both state and federal governments, and who are not aware that they should be given the same rights as heterosexual couples who are also getting health insurance coverage through their employer. Those 2 main parts—the Medicaid part and closing that parity gap for private health insurance coverage—are the broad policy takeaways as it relates to this paper, but I think as it relates to what the literature has found broadly as well.
AJMC: Is there anything else you’d like to mention relating to your research?
Bolibol: I mentioned this briefly, but I do want to touch on this because I think it is important, as well as the race and ethnicity and collapsing into one variable. We had to collapse LGBT into one variable by the nature of the data, that's how they reported it. But I want to emphasize that the community is not a monolith. The needs of individuals within the community varies by their identity and sexual orientation, and that's a very important factor that's not incorporated into our study and is actually not incorporated into a lot of studies. We kind of lump together LGBT as just like one identity when it's not. I want to point that out, because I think that's very important, and get ahead of any criticism along those lines, because I think it's rightfully so to be criticized that collapsing into one thing is not indicative of the different struggles that people face.
This transcript has been edited lightly for clarity.
Bolibol A, Buchmueller TC, Lewis B, Miller S. Health insurance coverage and access to care among LGBT adults, 2013-19. Health Aff (Millwood). 2023;42(6):858-865. doi:10.1377/hlthaff.2022.01493