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Ongoing LGBT Health Disparities Addressed by Affordable Care Act
AAMC Reporter: April 2014
—By Eve Glicksman
Passage of the Affordable Care Act (ACA) is drawing greater attention to how health policy may contribute to poorer health outcomes in the LGBT (lesbian, gay, bisexual, and transgender) community. While the ACA does not explicitly call for LGBT programs and services, carefully worded clauses attempt to eliminate all health care barriers and discrimination against Americans who have gotten the medical short shrift because of their sexual orientation or gender identity.
Until relatively recently, many discussions about LGBT health focused primarily on issues related to HIV/AIDS. While still germane, the agenda is broadening, especially since many within the LGBT community have numerous health concerns unrelated to HIV. Today there is growing recognition that individuals within the LGBT community have not received equal treatment in the grand scheme of medicine. In 2011, a landmark report on LGBT health by the Institute of Medicine documented extensive gaps in the understanding of what has been called “a hidden health demographic.” With the ACA, attention is shifting to how health care policy may contribute to poorer health outcomes in LGBT individuals, said Henry Ng, M.D., M.P.H., president of GLMA: Health Professionals Advancing LGBT Equality and an assistant professor at Case Western Reserve University School of Medicine.
Comparative studies have shown that LGBT individuals are more likely to be uninsured or underinsured, but cost has not always been the primary obstacle in their access to care. Arbitrary definitions of “family” additionally have prevented some from getting insurance for partners or children. Others have been denied coverage for preexisting conditions, including those that disproportionately impact LGBT communities, such as HIV or gender dysphoria.
The immediate impact of the ACA will be an increase in LGBT individuals who are able to obtain comprehensive health coverage. Many ACA exchanges will recognize domestic partnerships as well as nonbiological children raised by LGBT parents. Beyond that, the ACA will protect the LGBT population against health care discrimination for the first time in history, according to Ng. In addition to ensuring that no one can be denied health insurance based on their sexual orientation or gender identity, the ACA prohibits insurers from charging higher rates for preexisting conditions, rescinding coverage, or putting dollar limits on essential health care—all of which have been particularly detrimental for people with HIV/AIDS.
The ACA also created the National Strategy for Quality Improvement to develop strategies to address research, medical education, or health care policy gaps that contribute to health care disparities. For example, making recommended screenings part of essential care covered by insurers under the ACA will help to diagnose certain
cancers (rectal, breast, lung, colon, uterine, and ovarian) known to occur more frequently in the LGBT population at an earlier, more treatable stage. In addition, the ACA now requires insurers to cover treatment for mental health problems and substance abuse, which are more prevalent in the LGBT community and often related to stigma and discrimination.
Affordable health care is of little use, though, if physicians are not proficient in providing care to LGBT patients. Asking a gay man about his sexual history is often the extent of the average clinician’s LGBT sensitivity and competence, said John-Paul Sanchez, M.D., M.P.H., assistant professor in the emergency department at Albert Einstein College of Medicine and chair of the Einstein LGBT Steering Committee.
A survey of medical school deans in the United States and Canada, published in 2011 in the Journal of the American Medical Association, found that students get only five hours of LGBT-related training over the course of four years of medical school. That usually does not include time for students to practice history-taking techniques or behavioral questions related to mental health, sexually transmitted infections, and substance abuse. Trust problems can begin at the start if a physician does not know what name or pronoun to use when talking with a transgender person, Ng noted. Medical students also need to learn practice guidelines, which include Hepatitis A and B vaccinations for gay and bisexual men.
With this in mind, ACA provisions prioritize cultural competence standards and training to improve LGBT health outcomes. Physicians may not know that LGBT individuals who are Latino or African-American face “double the homophobia and marginalization” of nonminority LGBTs, which compromises their health status even more, Sanchez said. And most physicians have little appreciation or knowledge that LGBT people are at higher risk for smoking-related illnesses (chronic obstructive lung disease, heart disease, and cancer) because of greater tobacco use, he added.
Making a medical office comfortable and welcoming for LGBT patients also is important, said Kristen L. Eckstrand, Ph.D., an M.D. candidate at Vanderbilt University School of Medicine. A 2010 Lambda Legal Defense survey with 4,916 respondents found that 73 percent of transgender patients and 29 percent of lesbian, gay, and bisexual patients believed medical personnel would treat them differently if they disclosed their status. Small steps that include welcoming materials, such as a brochure on LGBT health issues in the waiting room or an institution’s nondiscrimination policy on the practice’s website, are good ways to show support for LGBT patients, she said.
The hidden health demographic
The University of Pennsylvania Health System (UPHS) is the latest teaching hospital to launch a program dedicated to LGBT health care. Beyond clinical care, the Penn Medicine Program for LGBT Health is tackling issues surrounding institutional climate, medical education, research, and community outreach. Physicians, nurses, and support staff throughout the institution are receiving cultural sensitivity training.
A major advantage of the program is that it has the resources to offer advanced, high-level specialty and subspecialty care through the larger health system, said Neil Fishman, M.D., UPHS associate chief medical officer and faculty adviser for the LGBT program. But he noted that outreach is needed to educate the community members on how to use enhanced benefits. “Many [LGBT individuals] are used to using the ER as their primary care option,” he said.
Medical schools and teaching hospitals likely will be increasing LGBT-related research, thanks to the ACA. Up to now, a fundamental lack of national LGBT-identity data collection and LGBT health baselines have thwarted advances in LGBT health, Sanchez said. While statistics on African-American and Hispanic identity have been collected for decades, federal surveys typically have not asked sufficient questions to assess sexual orientation, same-sex partnerships, or gender identity. The ACA now mandates that all federal data collection efforts include sexual orientation and gender identity tracking.
In response to the new requirements, the Department of Health and Human Services (HHS) is working to include sexual orientation and gender identity questions on national federal surveys. Having that data will enable researchers to analyze trends, target problems, compare data with non-LGBT respondents, and, ultimately, develop effective interventions based on the findings.
Over the next year, the National Institutes of Health is expected to convene its first Lesbian, Gay, Bisexual, Transgender, and Intersex Research Symposium, an indication that federal funding for LGBT research is being taken more seriously. Fishman believes that the biggest research gap in LGBT health surrounds mental illness. LGBT people are more likely than others to suffer from depression, substance abuse, anxiety, and teen suicide. Brigham and Women’s Hospital is now conducting research to identify risk factors that contribute to substance abuse disparities among LGBT youth.
The AAMC has been working on all these issues as well. The association’s Group on Diversity and Inclusion has highlighted the needs of LGBT faculty and has broadened data collection to include sexual orientation and gender identity.
In addition, the AAMC’s LGBT and Differences of Sex Development Patient Care Advisory Committee is submitting its thoughts about priorities in LGBT health care to HHS. Support for patients with differences in sex development is at the top of the AAMC committee’s list, said Eckstrand, committee chair and lead author. Naturally occurring chromosomal, anatomical, or endocrine variations affect approximately one in 4,500 people who can be overtreated, misunderstood, or marginalized by physicians and researchers, she said. The committee also is calling for more LGBT research and support for community programs that help vulnerable LGBT populations, such as children and adolescents and the homeless.
The architects of the ACA cast a wide net that allows advocates to push the boundaries of inclusion for minorities in health care. Still ongoing is the debate surrounding whether health insurers can exclude coverage of certain types of care, such as sex reassignment surgery for transgender persons. As more LGBT patients gain access to care, take advantage of preventive care, and receive earlier diagnoses, Eckstrand predicts decreasing morbidity and mortality from certain health conditions among LGBT patients, especially among those with chronic conditions.
HHS is trying to address health care loopholes that have emerged as a result of the ACA’s lack of a universal definition of “family.” This has caused state and federal laws to collide in states where same-sex marriage is not recognized. In one such state, Ohio, legal issues have arisen for gay parents (married in another state) with an adopted child who did not qualify for family policy coverage. Instead, the family had to obtain three individual plans at a higher cost. In another case, a lesbian couple in Ohio is fighting to have both parents’ names listed on their child’s birth certificate because when only one parent is listed, the other parent is denied full medical decisionmaking privileges.
Health discussion that includes issues like marriage equality is “beyond the scope of what we used to teach in medicine,” Ng said. But the reality, he noted, is that we can’t talk about illness and health outcomes in the absence of cultural and societal constructs.
“Many [LGBT individuals] are used to using the ER as their primary care option.”
—Neil Fishman, M.D.