By TIMOTHY M. WESTMORELAND
& JEFFREY S. CROWLEY
Two Supreme Court rulings this summer helped assure that the lesbian, gay, and bisexual (LGB) community reaches health care equality with their non-LGB peers.
The King v. Burwell case upheld the federal subsidies created by the Affordable Care Act (ACA) to help all income-eligible people access affordable private plan insurance in the ACA’s health care marketplaces. Consequently, nearly nine out of 10 LGB adults (88.9 percent) now have some form of health insurance up from just 78.2 percent before the ACA was implemented. These gains mirror those made across other segments of the population.
The ACA also includes provisions that prevent insurers and providers from discriminating against people based on sexual orientation or gender identity. This provision was not directly under question in the King v. Burwell case. If, however, the Court had ruled in favor of the law’s opponents, it is likely these protections would have reached far fewer people.
The second case, Obergefell v. Hodges—which established a Constitutional guarantee for marriage equality across the United States—also had an impact on health care in the LGB community. For the first time for many same-sex couples, a legally recognized marriage meant having access to a spouse’s health insurance. This is to say nothing of what the ruling clears up for same-sex couples when it comes to hospital visits, do-not-resuscitate orders, and the general effects on an individual’s mental and physical health of not having to worry about whether or not the government accepts the validity of a couple’s relationship.
But as was evident from the court battle over a Kentucky clerk’s responsibilities to issue marriage licenses to same-sex couples, compliance with the Supreme Court’s rulings does not always come immediately or easily. Further, despite the newfound marriage equality enshrined in law, the LGB community still faces barriers to accessing health care at equal rates as straight individuals. A new study of survey data, published in the October issue of Health Affairs and authored by researchers at the Urban Institute in Washington, D.C., illustrates that despite recent landmark cases moving the needle on LGB rights and quality, there is still work to be done.
The authors of the study find that even with the increase in the number of LGB adults with health insurance, nearly a quarter of all LGB adults (24.4 percent) reported having problems accessing care over the past year compared to just 16.1 percent of non-LGB adults reporting the same problems. This could be because many of the newly insured had yet to find a doctor or they had so many health issues that went untreated while they were uninsured that it has simply taken more than 12 months to access all the care that they require. Even more troubling is the finding that more than four in 10 LGB adults (42.6 percent) reported having an unmet care need as a direct result of costs over the last twelve months, compared to just 32.4 percent on non-LGB adults reporting the same problem.
While these gaps may lessen, this is no time for complacency. Now that the barrier of health coverage has been reduced, the LGB community and their providers must refocus efforts on eliminating other access barriers in order to eliminate disparities in knowledge of HIV status; adapting the health system to promote widespread, affordable access to pre-exposure prophylaxis to prevent HIV infection; working to ensure early and sustained access to antiretroviral therapy that leads to viral suppression; and routinely screening and treating for other sexually transmitted infections. It also means addressing a broader array of issues directly affecting LGB people including access to breast and cervical cancer screening and tobacco cessation services, among others. Before we turn our attention away from making the ACA work more effectively, however, ongoing advocacy and awareness-raising efforts are also needed in the LGB community about what health insurance options are available, and which plans best suit different individuals and families and their specific health needs.
Though the federal government and the court system have written some aspects of equality into law, the march is not over yet. It is now time to turn law into reality.
Timothy Westmoreland is professor from practice at the Georgetown University Law Center, as well as a senior scholar at the Law Center’s O’Neill Institute for National and Global Health Law. Jeffrey S. Crowley is a distinguished scholar and program director of the National HIV/AIDS Initiative at the O’Neill Institute.