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It’s happening: How healthcare reform will affect the LGBT community

It’s happening: How healthcare reform will affect the LGBT community

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In February 2012, Health and Human Services Secretary Kathleen Sebelius spoke in Philadelphia at the first of several White House summits on LGBT issues in health care. “There are still many areas where we can do more to ensure equal opportunity for LGBT Americans,” Sebelius stated, adding, “the Affordable Care Act is a huge step forward in closing LGBT health disparities.”

Many – but not all – of Colorado’s LGBT community advocates and health experts agree with Sebelius’ remarks, hopeful that the ACA will expand access and address many of the known issues in LGBT health care. “The benefits of the Affordable Care Act are enormous for our community,” said Dr. Mark Thrun, Director of HIV and STD Prevention and Control at Denver Public Health.

President Obama signed the ACA into law in March 2010 after a prolonged battle in Congress, which itself came after decades of failed attempts by Democrats and progressive activists to overhaul the health care system to expand access to the roughly 50 million Americans that year who still remained uninsured. The law, which dubbed “Obamacare” has become the President’s signature first-term achievement, brought unprecedented political uncertainty even after it was signed – challenged both in the newly-Republican 2011 House of Representatives and in state lawsuits against the federal law that advanced to the Supreme Court, where the ACA was upheld in a narrow 5-4 decision. That fight was followed by the 2012 presidential campaign, in which GOP nominee Mitt Romney promised to work on repealing Obamacare his first day in office, if elected.

With the president’s re-election instead, and Democrats maintaining control of the U.S. Senate, it’s finally safe to say that the ACA will be law for the foreseeable future – inviting a closer look at what it entails for the LGBT community. Some of its effects are left to be decided by states, and millions of Americans inside the LGBT community and out are still unaware or unclear about how they’ll be affected. When key provisions are implemented in 2014, the ACA will expand health insurance coverage to millions while establishing a comprehensive patient bill of rights that forbids discrimination based on preexisting conditions and prevents insurers from dropping patients without cause. Many ACA protections are already in place, addressing some known inequalities for LGBT people seeking health care.

KarenScarpella

“It’s going to be harder … to deny the poorest insurance for things that are not transition related, which is an improvement, but the biggest expense is transition care, and that’s not going to be covered.”

– Dr. Karen Scarpella,
Gender Identity Center of Colorado

But the ACA faces scrutiny even among some LGBT activists. Karen Scarpella, Executive Director and Program Director at the Gender Identity Center of Colorado, said the ACA leaves out important protections that trans Coloradans need. “It’s going to be harder for people to deny the poorest insurance for things that are not transition related, which is an improvement, but the biggest expense is transition care, and things related to being trans, and that’s not going to be covered,” Scarpella said. Scarpella also raised concerns about the ACA’s economic impact. “When they start mandating employers to provide this, there’s going to be fewer jobs. Transgender people are going to have a harder time finding jobs, further pushing them into the poorest [category],” she said.

LGBT issues in the health care system were detailed by statewide advocacy organization One Colorado in its Educational Fund survey, Invisible: The State of LGBT Health in Colorado, conducted with more than 1,300 LGBT respondents in 2011 – after the ACA passed, but in the early stages of its implementation when many of its most crucial components were not yet in effect.

One Colorado’s study, of which Dr. Thrun was an advisor, found 10 percent of respondents reported living with no health coverage and 21 percent of respondents reported being refused medical services by health care providers.

“LGBT Coloradans, just like straight Coloradans, are often uninsured,” said Brad Clark, One Colorado’s Executive Director, who added that even those with health insurance face discrimination. “As a result of painful experiences with health providers, only 59 percent of LGBT Coloradans feel safe enough to be very open about their sexual orientation or gender identity with their health providers.”

One Colorado’s survey and efforts to track LGBT health needs in Colorado are part of a growing national trend supported by local groups and even President Obama’s White House to address LGBT health care access issues. Beginning with a White House executive order in 2010, hospitals that receive federal dollars through Medicare or Medicaid are required to honor a patient’s designation of who can be a visitor regardless of marital status, allowing visitation rights for same-sex partners. In April of 2011, Secretary Sebelius issued a nondiscrimination policy protecting LGBT individuals seeking federal HHS medical services. And in September of 2011, the Centers for Medicare and Medicaid Services stipulated the rights of same-sex partners to make medical decisions on behalf of patients.

Dr. Thrun, who was a co-chair of Gov. John Hickenlooper’s Health Care Policy and Financial Transition Team and appointed by the governor as an advisor to the State Medical Assistance and Services Advisory Council, spoke with Out Front about key measures under the ACA that he says have a powerful impact on the LGBT community. “There’s five major things the Affordable Care Act will do that will benefit the LGBT community, many of which overlap with the benefits to the population as a whole,” Thrun said.


Expanded options for coverage

Expanding coverage was at the heart of the political movement that led to the ACA, and the law addresses that through three different expansions of coverage.

“New coverage options, the most important aspect of the ACA, is simply the new means by which people will have access to health insurance, access to health care,” Thrun said, explaining the three new routes.

BradClark

“[Because of] painful experiences with health providers, only 59 percent of LGBT Coloradans feel safe enough to be very open about their sexual orientation or gender identity with their health providers.”

– Brad Clark, One Colorado

The first option, already in place, covers young adults. As of September 2010, individuals up to the age of 26 can stay on their parents’ employer health insurance, “which is huge for many young LGBT folks,” Thrun said. “They’re able to stay on their parents insurance as they develop their own careers. It’s covering the gap that many young adults used to have.”

The second option is a Medicaid expansion to cover low-income people outside the margins of the current program’s reach. Medicaid, the existing federal program funding health care for poor individuals and families with little or no other means of getting care, is currently available to those below the poverty line and with qualifying circumstances – particularly children and those with disabilities. In 2014, under an ACA provision that governors can opt to adopt or reject, states can receive federal funding to expand Medicaid to cover all individuals living at or below 133 percent of the federal poverty level, which is about $14,800 for an individual and $30,600 for a family of four. On Jan. 3, Gov. Hickenlooper announced Colorado would participate in the expansion, which is expected to provide services to more than 160,000 Coloradans.

“It is important to note that these are the people who critically need services,” said Clark in a One Colorado statement following Gov. Hickenlooper’s announcement. “We are pleased Colorado is moving forward with implementation of the Affordable Care Act’s new Medicaid program. This Medicaid program will provide access to many LGBT families and individuals who have faced barriers to affordable health care for far too long.”

One Colorado’s 2011 study revealed who might benefit most from the expansion, noting that 8 percent of lesbian and gay respondents had been unemployed for more than a year, opposed to 4 percent of heterosexuals in Colorado. Beyond that, a recent study by the National Center for Transgender Equality revealed that 15 percent of transgender Coloradans live on less than $10,000 a year.

The third coverage option the ACA will create is through Affordable Insurance Exchanges, a state-run marketplace where individuals can purchase their own health insurance and small businesses can purchase coverage for employees. “The exchanges will offer a great opportunity for people who don’t have insurance through their jobs or other means,” said Thrun, “for those people between 133 percent and 400 percent of federal poverty level.”


Elimination of exclusions for pre-existing conditions

The ACA also bans insurance providers from rejecting applicants because they have previous medical conditions or risk factors – which is especially pertinent to LGBT people whose conditions, such as HIV or a need for transition-related health care, can be expensive.

“Beginning in Jan. 2014, insurance companies won’t be able to keep you from choosing their policies simply because of a pre-existing condition,” Thrun said, “which will open up opportunities for people to be covered.”

TimSchuetz

“We are very excited about the possibilities that health care reform will bring to those living with HIV. Currently, fewer than one in five people living with HIV in the United States have private insurance, and nearly 24 percent do not have any coverage at all.”

– Tim Schuetz, Colorado AIDS Project

Tim Schuetz, Chief Development Officer at the Colorado AIDS Project, said, “We are very excited about the possibilities that health care reform will bring to those living with HIV. Currently, fewer than one in five people (13 percent) living with HIV in the United States have private insurance, and nearly 24 percent do not have any coverage at all.”

The pre-existing condition provision already partly in effect – as of 2010, insurance companies can no longer exclude minors for pre-existing medical conditions, and adults can sign up for the Pre-existing Condition Insurance Plan to acquire coverage until the ACA goes into full effect in 2014.

A 23 year old who identified himself as an FTM (female to male) trans person living in Colorado spoke with Out Front about the discrimination he faced when trying to acquire health coverage prior to the passage of the ACA. Because of possible health care discrimination for revealing himself as trans, he asked to remain anonymous. “As a teenager, I wasn’t able to be covered on my parent’s insurance,” he said. “So, when we went to get independent insurance for me, I was denied because of gender identity disorder, a GID diagnosis,” the official diagnosis that goes on a trans person’s medical record allowing the patient to seek hormone therapy or gender-reassignment surgery. “I was unable to be covered because of this pre-existing condition.”

The young man is now taking advantage the ACA provision allowing him to remain on his parents’ health insurance plan until the age of 26.

“There’s so many trans people who are going to be able to get access to insurance,” he said, adding that banning discrimination based on pre-existing conditions is “one of the major victories for the trans community with the ACA.”


Preventative services and Elimination of lifetime limits

The ACA places new emphasis on funding preventative care, seeking to avoid health conditions or catch them early before they result in advance diseases in which case treatment is more expensive and less effective.

“The Affordable Care Act expands coverage for preventative services, coverage for preventative sexual health services for women, coverage for HIV screening for gay men,” Thrun said, adding that those who take advantage of this “won’t have to pay co-pays to receive those services, which is huge for our community.” In addition, individuals living with HIV or AIDS will benefit from the ACA’s provision within the Patient Bill of Rights prohibiting lifetime dollar limits established by insurers for patients with chronic diseases or serious illnesses that add up to large costs over time.

Lambda Legal reported that a 2006 health care overhaul in Massachusetts that is similar to the ACA coincided with a 37 percent decrease in new HIV infections there between 2005 and 2008, at the same time that new infections increased by 8 percent nationally.

Schuetz said “this effort increased the opportunities for federal money to be focused on preventative care and less on primary care and complications associated with an AIDS diagnosis,” adding that CAP hopes to see similar reductions in HIV infections in Colorado with the ACA.


Improved data collection

The ACA authorizes HHS to gather crucial demographic information on national health care disparities. In June of 2011, Secretary Sebelius took advantage of this law when she announced that by 2013, HHS would be adding questions on sexual orientation and gender identity to their central database, the National Health Interview Survey.

“The ACA will improve some of the data that we have on health disparities in the LGBT population,” said Thrun.

In addition, the HHS-run website at www.healthcare.gov includes search tools to help people find providers covering same-sex domestic partners.

Community groups are taking advantage of the policies. One Colorado plans to increase community awareness of the changes the ACA entails, Clark told Out Front, enabling LGBT patients navigate and make the most of them. “One of the next steps after policies are implemented is education in our community and making sure that people are able to navigate [the ACA] and have access,” he said. “We are working with the Colorado Medical Society and Denver Medical Society to develop and implement educational programs to fill existing gaps in physician understanding of LGBT health disparities.”

One Colorado also recently hired a Health Policy Director to work with an existing LGBT Health Steering Committee to ensure same-sex partners and their families are not excluded from health plans and that the medical needs of transgender Coloradans are met.


Limited protection against discrimination

Provisions in the ACA allowed LGBT-friendly regulators to enforce some measures of protection against health care discrimination against LGBT identities, but some still point to work that remains.

MarkThrun
Photo by FlorBlakePhoto.com

“Through this expansion of health care, through these new exchanges, through the new Medicaid program, we have regulations to fall back upon. Our families can’t be discriminated against.”

– Dr. Mark Thrun, Denver Health

“In March of 2012, The Department of HHS put out regulations that prohibited discrimination based on sexual orientation and gender identity,” said Thrun. “Through this expansion of health care, through these new exchanges, through the new Medicaid program, we have regulations to fall back upon. Our families can’t be discriminated against.”

In addition, Sebelius confirmed last July that the ACA’s language concerning sex-based discrimination protection included gender identity. Transgender individuals who face discrimination from any federally funded health service or program can seek help from the Office of Civil Rights at the HHS.

The transgender community is one of the most vulnerable demographic groups when it comes to health coverage. One Colorado’s survey revealed that only 38 percent of transgender respondents had sufficient coverage for their medical needs, while 54 percent replied they were denied health care services.

Scarpella said there are still shortfalls that need to be addressed during the implementation of the ACA. “There’s a lot of transgender people who believe they will be able to get care because they are no longer denied based on pre-existing conditions,” she said. “It might help transgender people get overall health care, but what they’re most worried about is how they’re going to pay for their transition care.”

“Transition related care is likely to remain uncovered,” Thrun said. “This is an issue that One Colorado has taken on as one of their primary areas of focus this year, and we are hopeful we will see improved access to care for transgender Coloradans because of it.”


Secretary Sebelius acknowledged at the Philadelphia summit that there were still many deficiencies when it came to fair health care treatment for LGBT people. “But I am confident that the progress of the last three years will continue because ultimately, the goal we are working towards is the goal that’s at the heart of what this country stands for: the idea that every American, no matter who they are or where they come from, should have the same chance to reach their full potential.”

For more info on how the Affordable Care Act will impact LGBT health care visit “New Options for LGBT Americans” at Healthcare.gov.

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