Health Policy$ense

Advancing LGBTQ Health – Hot topics on the national stage

Ian Jeong

Although Section 1557 of the ACA may not be well known to the public, it took center stage at the recent Gay and Lesbian Medical Association (GLMA) annual conference in Portland, Oregon. The conference educates practitioners and students about the unique health needs of lesbian, gay, bisexual, transgender and queer (LBGTQ) individuals and families, and reports on the latest research on LGBTQ health. Here are some of the latest research and policy developments emerging from the conference.

Section 1557 of the ACA

The most talked about policy on LGBTQ health was Section 1557 of the Affordable Care Act, which prohibits discrimination based on race, color, national origin, sex, age or disability. It is the first federal civil rights law to prohibit sex discrimination in health care. Previously, the Department of Health and Human Services (HHS) enforced regulations on discrimination based only on race, color, national origin, disability, or age. Section 1557 grants equal access to facilities, provides access to preventive health care, including “cross-sex” treatments (e.g., trans male patients accessing gynecological care), and bars categorical exclusions on any transition-related care. HHS recently closed the comment period on its proposed rule on Section 1557 and will soon develop final regulations to implement the provisions.

Attitudes of health care providers     

Researcher Janice Sabin of the University of Washington studies implicit and explicit attitudes of health care providers toward lesbian women and gay men. In a recent study, she and her colleagues found pervasive implicit preferences among heterosexual health care providers for heterosexual individuals versus lesbian and gay individuals. Her findings support many LGBTQ patients’ anecdotes of forgoing health care because they are afraid providers may discriminate against them on the basis of their gender identity or sexual orientation.

As a nursing student, I was interested in  Sabin’s finding that this implicit heterosexual preference was particularly prevalent among nurses. This finding is unsurprising based on the nursing community’s relatively limited focus on improving care for LGBTQ patients. A 2010 review of 5000 nursing-related publications found that just eight focused on LGBTQ health. In a separate study, nurse educators reported that they feel unprepared to educate students on LGBTQ health, although they agree it is important for nursing students to learn about this topic.

As a next step, it will be important to study how providers’ attitudes toward sexual minority patients affect quality of care and health outcomes.

Access to care

Although more LGBTQ individuals now have insurance, their access to care has not significantly improved. According to a study by Urban Institute’s Laura Skopec and Sharon Long, while insurance coverage and the likelihood of having a usual source of care has increased significantly for LGB adults, there are no significant changes in the existing disparities in access to and affordability of care.

Insurance coverage may still fall short of providing all necessary care to the trans community. As part of a panel focused on trans-inclusive insurance coverage, Danni Askini of the Gender Justice League spoke of the trans community’s fight to demonstrate the medical necessity of care directed at secondary sex characteristics. Even for patients with insurance, public or private, these services are often seen as cosmetic and therefore not covered by insurance, while surgeries involving primary sex characteristics are covered under some states’ Medicaid. For example, at Penn, the Penn Student Insurance Plan covers mastectomy, gonadectomy, and genital reconstructive surgery, but considers services related to secondary sex characteristics, that many trans patients have identified as medically necessary, as “cosmetic”. Expanding the services that insurance plans categorize as medically necessary will allow trans individuals to take control of their transition and affirm their gender identity as they see fit.

Healthcare Equality Index

Many health care providers are working towards being LGBTQ-inclusive. From 2013 to 2014, the Healthcare Equality Index (HEI), the national benchmarking tool run by the Human Rights Campaign that rates the LGBTQ-friendliness of hospitals, had a 109% jump in hospital participation. HEI now has 1504 participating hospitals, 427 of which have the designation of being a “Leader in LGBT Healthcare Equality”. Earlier this year, the University of Pennsylvania Health System received this designation for: inclusive policies and practices related to LGBTQ patients, visitors and employees; nondiscrimination education and training programs; and, research on LGBTQ health. Penn Medicine has also launched the Penn Medicine Program for LGBT Health, which demonstrates its commitment to LGBTQ inclusivity through focused research efforts, improved patient care and an inclusive institutional climate.

These recent developments, among others, provide the framework that health care providers and patients can rely upon to address and promote the wellbeing of the LGBTQ community. I am excited to see how the ACA’s anti-discrimination protection, the HEI and new research will help make health care organizations and health professional schools more inclusive environments for all individuals.