The Affordable Care Act: Building Health Equity for LGBT People Kellan Baker, MPH, MA Out2Enroll Steering Committee

Learning Objectives By the end of this session, learners will be able to: 1. Describe how the Affordable Care Act (ACA) has influenced access to health care for LGBT people 2. Identify strategies for the outreach and enrollment of LGBT people into health care under the ACA 3. Explain other ways that the ACA has impacted LGBT health, including data collection, health insurance coverage, and prevention

Our mission: To connect LGBT people with their new coverage options under the ACA. “Be out. Be healthy. Get covered.” Federal Agencies Project OUT2ENROLL

The ACA: Health Centers and ASOs  Health Centers and ASOs serve a large number of uninsured or underinsured people  LGBT people are disproportionately un- or underinsured  Many ASOs and CBOs have developed relationships with their local LGBT communities  Health Centers across the U.S. are serving LGBT people  Health Centers, ASOs, and CBOs have a long history of helping clients navigate the health care landscape

What is LGBT?  LGBT: Lesbian, Gay, Bisexual, Transgender  Sexual Orientation: The L, the G, the B  Lesbian and Gay  Bisexual  Straight (also known as heterosexual)  Gender Identity: The T  Gender identity is each person’s deeply felt, internal knowledge of their own gender

Transgender Terminology  Transgender: A person whose gender identity is different from their assigned sex at birth  Trans man: A man who was assigned female at birth – gender pronouns: he/him/his  Trans woman: A woman who was assigned male at birth – gender pronouns: she/her/hers  Genderqueer/gender-nonconforming: A person who does not identify as exclusively male or female – gender pronouns might be they/them/theirs (but best to politely ask)

Gender Transition  Gender transition is the process in which a transgender person changes from one gender to another  Usually involves social, legal, and medical changes:  Social – clothing, hair style, preferred name and pronouns  Legal – legal name and legal gender  Medical – hormone therapy, mental health counseling, sex reassignment surgeries (often referred to as “SRS”)  Depending on where they are in transition, a transgender person might use a name and/or gender that’s different from what’s on their legal ID

Faces of Transgender People

Terms to Avoid X “Homosexual” Instead use “gay” or “lesbian” X “Transsexual”Instead use “transgender” or “trans” X “A transgender”Instead use “a transgender person” X “Sex change”Instead use “gender transition” X “Sex change surgery”Instead use “sex reassignment surgeries”

Polling Question Which of the following is not a term describing sexual orientation? a) Straight b) Transgender c) Heterosexual d) Lesbian

Polling Question How many people in the United States identify as LGBT? a) 700,000 b) 1.3 million c) 9 million d) 35 million

Source: Movement Advancement Project, 2013 Where LGBT People Live

LGBT People Come From Every Community

LGBT Parents Source: Movement Advancement Project

What comes to mind when you think about LGBT health?

LGBT Health Disparities ↑ Tobacco and other substance use ↑ Mental health concerns, such as depression and suicide attempts ↑ Certain cancers, such as breast cancer ↑ Experiences of bullying and violence ↑ HIV/AIDS Source: The Health of Lesbian, Gay, Bisexual and Transgender People (Institute of Medicine, 2011), Healthy People 2020

LGBT Health Disparities Homelessness Lack of legal recognition & protections Poverty Anti-LGBT discrimination Racism & other discrimination Lack of insurance coverage Lack of LGBT cultural competency Source: The Health of Lesbian, Gay, Bisexual and Transgender People (Institute of Medicine, 2011), Healthy People 2020 LGBT Health Disparities

I was refused needed health care. Health care professionals used harsh or abusive language. Health care professionals were physically rough or abusive. Health care professionals refused to touch me or used excessive precautions. Source: Lambda Legal, “When Health Care Isn’t Caring,” 2010 Graphs of Experienced Discrimination

Uninsurance Among LGBT People Source: Gallup, 2014

Source: Center for American Progress, 2014 Uninsurance Among Low- and Middle-Income LGBT Adults

Transgender Insurance Issues  Transgender people are frequently denied insurance coverage and health care just because of who they are  Discriminatory exclusions remain in many insurance plans  Examples of transgender exclusions:  “Procedures or medical care performed in connection with sex reassignment”  “Procedures, services, and supplies related to sex transformation”  “Transsexual surgery, regardless of medical necessity”  “All services related to gender dysphoria or gender identity disorder"

Types of Care Affected by Exclusions  “Sex-specific” preventive screenings:  Cervical Pap tests  Mammograms  Prostate exams  Medically necessary health care related to gender transition:  Mental health counseling  Hormone therapy  Sex reassignment surgeries  Any other kind of care a trans person might need

Polling Question What types of health care can be blocked by transgender insurance exclusions? a) Preventive screenings like a mammogram b) Hormone therapy c) Treatment for pneumonia, a broken arm, or a heart attack d) SRS e) All of the above

BUT: Change Is Happening! Medicare removed its exclusion in 2014 Federal guidance requires plans to cover preventive screenings for trans people ACA Section 1557 proposed rule:  Prohibits transgender insurance exclusions  Prohibits providers from discriminating against trans people  Applies to all entities that touch federal financial assistance, including Marketplace plans, state Medicaid programs, Medicaid Managed Care plans, and Medicare Advantage plans

Key ACA Benefits for LGBT People  LGBT Nondiscrimination  “Under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability.”  Complaints of discrimination can go to the Office for Civil Rights ( HealthCare.gov ( ), state insurance commissioner, state attorney generalwww.hhs.gov/ocr  Relationship Recognition  Straight and gay married couples are treated exactly the same by the Marketplace and Medicaid with regard to eligibility, household size, income, etc.  Family/spousal coverage and APTCs are equally available to straight and gay spouses  For unmarried parents, a child’s eligibility for APTCs is tied to the parent that claims the child on their federal taxes  Better Quality Coverage  Coverage of key health care services, such as preventive screenings, mental health, and prescription medications  All consumers have the right to appeal denials of coverage

LGBT People Want to Get Covered  More than 90% of low- and middle-income LGBT people say health insurance coverage is very important to them  50% of low- and middle- income LGBT people have never shopped for coverage before  80% want enrollment help from assisters with specific training on LGBT issues Source: Center for American Progress, 2013/2014

Ways to Reach LGBT People  Leverage existing relationships with the LGBT community  Create new partnerships with local LGBT organizations  Use relevant images, language, and content  Participate in LGBT- friendly events, like LGBT Pride fairs

Find this and other graphics on Out2Enroll’s Facebook page and Out2Enroll OUT2ENROLL Graphic

OUT2ENROLL Graphic 2

Let People Know Where You Are To sign up after this training, visit

After you’ve reached out… What’s next?

Create a Safe & Welcoming Environment in your ASO/CBO/Health Center Display LGBT-inclusive nondiscrimination policies Post “safe space” or rainbow stickers and posters Have LGBT reading materials available in waiting areas Provide unisex bathrooms Allow people to point or write down answers themselves State that you ask the same questions of every applicant

Don’t Make Assumptions  Remember that LGBT people are diverse:  Gender and gender identity  Sexual orientation  Relationship status  Family configuration  When referring to patients, clients, or their families, use gender-neutral language, such as “partner,” “spouse,” and “parent”

Be Aware of Language  Don’t make assumptions about a patient or client’s gender on the basis of voice or what’s on their ID documents  When in doubt, politely ask rather than guessing:  “How would you like me to refer to you?”  “What pronoun do you use?”  “How would you like to be addressed?  Write down and consistently use the appropriate name and gender pronoun  Simply apologize and move on in case of a mistake

Filling Out the Application  Name and gender – In conversations with the person, use the name and gender pronoun the person prefers; on the application, recommend that the person use the name and gender they use to file their taxes  Relationship status – Married gay couples have the same rights to joint financial help and family coverage as married straight couples  Household configuration – All spouses must file joint federal income taxes in order to be eligible for subsidies

Filling Out the Application  Plan exclusions – Transgender exclusions cannot be found in the Summary of Benefits and Coverage; they can only be seen in the Evidence of Coverage or Certificate of Coverage  Plan formularies – Make sure that medications used to treat conditions such as HIV are not in high/unaffordable cost-sharing tiers  Provider networks – Ways to identify LGBT-friendly providers include asking local LGBT organizations, looking at the provider directory at and looking up local Ryan White providers at

Polling Question: Name something your organization can do to best reach and serve LGBT people.

Case Studies

Case Study #1: Maria At a yearly wellness visit at her health center, Maria asks to learn more about enrolling in health insurance coverage. In addition to getting insurance for herself, Maria would also like to get coverage for her partner Jenny, and their daughter Sarah.

What is the most important determinant of whether Maria and Jenny have the right to get family coverage together? a) If they have children together b) If they are married c) If they file federal taxes together d) What state they live in

Case Study #2: Jimmy Jimmy comes to your weekly STI clinic frequently for testing. During one visit, he asks about enrolling in health insurance coverage. He lets you know that he wants a plan that includes LGBT-friendly providers who have expertise in the treatment of HIV.

What are some plan design issues that Jimmy needs to keep in mind as he looks for a plan?

Case Study #3: Sam Sam contacts you by phone to learn more about enrolling in health insurance coverage. When you address Sam as “sir,” Sam corrects you by saying, “Actually, it’s ma’am.”

What should you do next? (choose all that apply) a) Ask what gender Sam’s ID says and just use that b) Make a note that Sam identifies as female c) Consistently refer to Sam as “she” in the future d) Apologize and move on

Sam says she needs a plan that covers SRS. How can you help her?

Don’t Forget to Sign Up! To sign up after this training, visit

Online LGBT Resources  Out2Enroll:  Affordable Care Enrollment (ACE) TA Center:  Key Lessons for LGBT Outreach and Enrollment Under the Affordable Care Act (Out2Enroll, 2014): content/uploads/2014/07/O2E_KeyLessons_FINAL.pdfhttp://out2enroll.org/wp- content/uploads/2014/07/O2E_KeyLessons_FINAL.pdf  Where to Start, What to Ask: A Guide for LGBT People Choosing Healthcare Plans (Strong Families Coalition, 2015): guidehttp://strongfamiliesmovement.org/lgbt-health-care- guide  Moving the Needle: The Impact of the Affordable Care Act on LGBT Communities (Center for American Progress, 2014): the-needle/ the-needle/  LGBT Health Training: The National LGBT Health Education Center

Thank you! Kellan Baker Katie