LGBT people were already more likely to experience physical and mental health problems and less likely to be insured than straight and cisgender counterparts before Donald Trump became president. We already faced difficulty accessing health care. Now, we’re facing a crisis.
Under Barack Obama, the Department of Health and Human Services as well as the departments of Education, Justice, and Housing and Urban Development issued guidelines stating that discrimination on the basis of gender identity is banned by federal law. Notably, HHS interpreted language in the Affordable Care Act to cover LGBT people. Unfortunately, Congress didn’t pass anti-discrimination legislation, and guidance and regulations can be withdrawn by subsequent administrations. That’s what’s happening now.
Under Trump, and beginning in May 2017, HHS has moved to withdraw the Obama-era interpretation of the ACA, eliminating protections for LGBT people in health care. Compounding the refusal to protect transgender people, the administration created an entire new division within its Office of Civil Rights to protect the providers—and insurers—who want to discriminate against LGBT people, women, and others on the basis of religion. Trump’s razed other administratively enacted protections for LGBT people by rescinding, delaying, or interpreting them.
“Discrimination puts LGBT people at heightened risk for a range of health issues, from depression and addiction to cancer and chronic conditions,” according to Human Rights Watch’s Ryan Thoreson. “Instead of treating those disparities as a public health issue, HHS is developing politicized rules that will make them much worse.”
For a new report documenting the heightened barriers to health care that LGBT people now face, Thoreson interviewed 81 people affected by or advocating against anti-LGBT discrimination in health care. He focused on Mississippi and Tennessee, where anti-discrimination laws don’t protect LGBT people—and where legislators have created specific exemptions for health care providers to refuse to serve LGBT people on the basis of religious beliefs.
The health care needs of the LGBT community are substantial. Lesbian, gay, and bisexual people experience psychological distress and addiction at higher rates than straight folks. Lesbian and bisexual women are more likely to have multiple chronic conditions. Thoreson also points to state-level data indicating transgender people suffer from obesity, depression, and cognitive difficulties at higher rates than cisgender people. They’re also more likely to avoid health care providers, even when it means letting a condition go untreated.
Thoreson notes that these effects are most serious in rural areas, but evident even where LGBT people have greater social and legal conditions. That makes sense. The link between discrimination and negative health outcomes couldn’t be clearer. A 2017 survey found that nearly 70 percent of LGBT people who’d experienced discrimination in the past year were negatively psychologically affected; almost 45 percent were negatively physically affected.
Oh, and LGBT people are twice as likely to be uninsured as non-LGBT folks. We’re also a lot more likely to live in poverty, not in the least because of employment discrimination. The figures are bleakest for transgender people. The 2015 U.S. Transgender Survey found 15 percent of respondents were unemployed, and 29 percent lived in poverty. One-third of those who responded had foregone health care because of cost.
Beyond the deleterious sequelae of discrimination, LGBT people also have distinct, sometimes intrinsic health care needs. Same-sex couples seeking to conceive may require fertility assistance. HIV-positive members of the LGBT community need access to treatment; those at risk of contracting HIV should have the option of preventative care. Transgender people who want to transition medically could need anything from puberty blockers and hormone replacement therapy to gender-affirming surgeries.
In 2017, 8 percent of LGB and 29 percent of transgender respondents to a national survey reported being turned away by a health care provider. An earlier survey by the National Center for Transgender Equality found that one-third of respondents had encountered negative reactions from health care providers. Twenty-three percent had forgone care because of concerns about negative treatment on the basis of gender identity.
Of course, the care that LGBT folks get is less likely to be adequate than that received by straight and cisgender people. For example, lesbian and bisexual women—especially those who are non-gender conforming—are less likely to be screened for colon, breast, and cervical cancer. As a result, we have higher rates of breast and cervical cancer than heterosexual women.
Things are getting worse: Conservatives’ hateful “religious liberty” agenda is fueling social as well as legislative discrimination. Thirty-seven states don’t prohibit health insurers from discriminating against LGBT people. Just 19 states (and D.C.) bar insurers from excluding medical care for transgender people, and 10 states explicitly bar Medicaid from providing transgender health coverage.
Thoreson’s report is exhaustive—and heart-wrenching. It’s a critical illustration of what’s at stake under this administration for LGBT people. A lawyer by training, Thoreson also notes Republicans’ religious liberty schtick—and the Trump administration’s war on LGBT people—violates U.S. international commitments. Among others, there’s the International Covenant on Civil and Political Rights and the United Nations interpretation of the ICCPR, which aligns closely with the concept of a constitutionally-protected right to human dignity that has been the foundation for gay rights at the Supreme Court.