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Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S.

Table 1: Alcohol Use, Cigarette Use, and Serious Psychological Distress Among Bisexual, Gay or Lesbian, and Heterosexual Adults ages 18-64, 2013
Five or more alcoholic drinks in 1 day at least once in past year Bisexual Gay or Lesbian Heterosexual
All adults 41.5% 35.1% 26.0%
Women 34.9% 27.7% 17.2%
Men 56.3% 41.8% 35.1%
Current cigarette smoker Bisexual Gay or Lesbian Heterosexual
All adults 29.5% 27.2% 19.6%
Women 29.4% 27.2% 16.9%
Men 29.6% 27.2% 22.3%
Experienced serious psychological distress in past 30 days Bisexual Gay or Lesbian Heterosexual
All adults 11.0% 5.0% 3.9%
Women 10.8% N/A 4.5%
Men N/A N/A 3.3%
All adults 41.5% 35.1% 26.0%
NOTE: N/A- data not available due to unreliability.
SOURCE:  Centers for Disease Control and Prevention, National Health Statistics Reports. (July 2014). Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013.
Table 2: Impact of Selected Federal Policy Changes on Coverage and Access toCare for LGBT Communities
Policy Key Provisions and Impact
The Patient Protection and Affordable Care Act (ACA)1
  • Broadens federal nondiscrimination in health care programs receiving federal funds and prohibits basing coverage eligibility, insurance premium pricing, benefit design, or any other aspect of coverage on sex, gender identity, or sex stereotyping.
  • Explicitly prohibits state insurance marketplaces and plans offering the essential health benefits from discriminating based on sexual orientation or gender identity.
  • Promotes data collection and analysis on sexual orientation and gender identity through federally-sponsored surveys and programs.
  • Individuals will no longer be denied coverage due to a pre-existing condition, such as HIV/AIDS, mental illness, or a transgender medical history.
  • New private plans are required to cover USPSTF recommended preventive services without cost sharing. Includes screenings for HIV, STIs, depression, and substance misuse.
  • Expands coverage to many uninsured persons through Medicaid and state-based health insurance marketplaces. Medicaid, in states that expand, will base eligibility solely on income (no categorical requirement) and tax credits are available to help subsidize the cost of coverage in marketplaces for low income individuals.
United States v. Windsor – Overturn of Federal Defense of Marriage Act (DOMA)
  • Overturned Section 3 of the Defense of Marriage Act, which limited marriage to persons of the opposite sex. Treats legal marriages between same-sex individuals the same as marriages between opposite sex individuals with regard to federal law.
  • Department of Health and Human Services2
    • Guarantees that same-sex married beneficiaries in Medicare Advantage plans who both need care in a skilled nursing facility can receive care at same facility.
  • Center for Consumer Information and Insurance Oversight (CCIIO) Guidance on IRS Ruling 2013-17 and Eligibility for Advance Payments of the Premium Tax Credit and Cost-Sharing Reductions
    • All Health Insurance Marketplaces are to recognize legal same-sex marriages when determining eligibility for Premium Assistance and Tax Credits.3
  • Centers for Medicare and Medicaid Services (CMS) Guidance to advise of the implications of the Windsor decision for Medicaid and CHIP4
    • Allows states to decide whether to recognize same-sex marriages when determining Medicaid eligibility.
  • Internal Revenue Service (IRS) Ruling 2013-175
    • Ruled that same-sex couples legally married will be treated as married for federal tax purposes, regardless of whether the couple lives in a jurisdiction that recognizes same-sex marriage or not (“state of celebration” takes precedent). Allows couples to file taxes as “married” and thus treats same-sex spousal health coverage as tax exempt for purposes of determining federal income tax.
    • If same-sex spouse received employer-based dependent insurance, the employee may apply for refund of excess federal income taxes paid on the value of the coverage for past 2-3 years.
  • Department of Labor Technical Release Number 2013-046
    • Requires all ERISA plans to include legally married same-sex couples in the definition of “spouse” and “marriage,” opening the door for broader dependent coverage of same-sex spouses.
  • Department of Defense Memorandum Subject: Extending Benefits to the Same-Sex Spouses of Military Members7
    • Legally married spouses eligible for dependent health coverage of service members and DOD civilian employees.
  • Department of Justice Letter to The Honorable John Boehner8
    • Extends VA and DOD spousal benefits to same-sex spouses by no longer enforcing Title 38 of the U.S. Code, which had previously limited benefits to opposite-sex marriages only.
  • Department of Labor, Wage and Hour Division- The Family and Medical Leave Act,
    • As a result of the DOMA ruling, the DOL expanded the definition of spouse under FMLA to include same-sex couples residing in a state that legally recognized same-sex marriage.9
    • Notice of Proposed Rulemaking10: In 2014, DOL proposed a further expansion of the definition of “spouse” to include all legally married same-sex couples.
Other
  • Presidential Memorandum- Hospital Visitation11
    • Executive order in 2010 stating hospitals that receive funds from Medicaid and Medicare are to respect the rights of patients to designate visitors, including those designated by legally valid advance directives.
    • Hospitals may not deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability.
    • Guidance issued in November 2010 supports enforcement of the right of patients to designate the person of their choice, including a same-sex partner, to make medical decisions on their behalf should they become incapacitated.
  • Centers for Medicare and Medicaid Services Memorandum 13-42-NH: Reminder- Access and Visitation Rights in Long Term Facilities12
    • LTC facilities must ensure that all individuals seeking to visit a resident be given full and equal visitation privileges, consistent with resident preferences within reasonable restrictions that safeguard residents.
  • Centers for Medicare and Medicaid Services- Medicaid Spousal Impoverishment Protections13
    • Protections have been extended to include same-sex spouses. This allows a spouse living in the community to maintain a certain level of assets when institutional expenses (usually a nursing home) threaten to deplete all resources and impoverish the community-based spouse.
  • National Institutes of Health- LGBT Research Coordinating Committee14
    • This committee was formed to consider recommendations of the Institute of Medicine’s study The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding and to suggest strategies for how the NIH can support research.
Table 3: Among Firms Offering Health Benefits, Distribution of Whether Employers Offer Health Benefits to Unmarried Same-Sex Domestic Partners, by Firm Size, Region, Industry, 2014
Offer Health
Coverage to
Same-sex Partners
Do Not Offer Health
Coverage to
Same-sex Partners
Not Encountered
Firm Size
All Small Firms
(3-199 Workers)
39% 19%* 42%*
All Large Firms (≥200 Workers) 49%* 45%* 5%*
Region
   Northeast 60%* 21% 19%*
   Midwest 28% 24% 47%
   South 25%* 22% 53%
   West 48% 11% 41%
Industry
   Manufacturing 69%* 20% 12%*
   Wholesale 38% 36% 25%
   Retail 25% 12% 63%
   Finance 55% 22% 23%
   State/ Local Government 16%* 27% 57%
All Firms 39% 20% 41%
* Estimate is statistically different from estimate for all firms not in the indicated size, region, or industry category (p<.05).
NOTE: The response option “not encountered” captures the number of firms that report not having a policy on the issue.  This response is distinguished from firms that report “no” since those firms have a set policy on the issue.
SOURCE:  Kaiser/HRET, Employer Health Benefits Survey, 2014.

 

 

Impact of Policies on Coverage and Access to Care