Transcript The ACA and LGBT People

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
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
Where LGBT People Live
Source: Movement Advancement Project, 2013
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
Anti-LGBT
discrimination
Poverty
Lack of legal
recognition &
protections
Homelessness
Racism &
other
discrimination
Lack of
insurance
coverage
LGBT Health
Disparities
Lack of LGBT
cultural
competency
Source: The Health of Lesbian, Gay, Bisexual and Transgender People (Institute of Medicine, 2011), Healthy
People 2020
I was refused needed health care.
Health care professionals used harsh or
abusive language.
Health care professionals refused to touch
me or used excessive precautions.
Health care professionals were physically
rough or abusive.
Source: Lambda Legal, “When Health Care Isn’t Caring,” 2010
Uninsurance Among LGBT People
30%
25%
20%
24.20%
22.00%
17.20%
16.70%
15%
23.70%
15.00%
17.60%
LGBT
13.20%
Non-LGBT
10%
5%
0%
Q3 2013
Q4 2013
Q1 2014
Q2 2014
Source: Gallup, 2014
Uninsurance Among Low- and
Middle-Income LGBT Adults
Source: Center for American Progress, 2014
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
(www.hhs.gov/ocr), HealthCare.gov (1-800-318-2596), state insurance
commissioner, state attorney general
 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 LGBTfriendly events, like
LGBT Pride fairs
Find this and other
graphics on Out2Enroll’s
Facebook page and
www.out2enroll.org
Out2Enroll
Let People Know Where You Are
To sign up after this training, visit www.bit.ly/O2Eassisters
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 www.glma.org, and looking up local Ryan White
providers at www.hab.hrsa.gov
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 www.bit.ly/O2Eassisters
Online LGBT Resources
 Out2Enroll: www.Out2Enroll.org
 Affordable Care Enrollment (ACE) TA Center: https://careacttarget.org/ace
 Key Lessons for LGBT Outreach and Enrollment Under the Affordable Care Act
(Out2Enroll, 2014): http://out2enroll.org/wpcontent/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): http://strongfamiliesmovement.org/lgbt-health-careguide
 Moving the Needle: The Impact of the Affordable Care Act on LGBT Communities
(Center for American Progress, 2014):
https://www.americanprogress.org/issues/lgbt/report/2014/11/17/101575/movingthe-needle/
 LGBT Health Training: The National LGBT Health Education Center
www.lgbthealtheducation.org
Thank you!
Kellan Baker
[email protected]
Katie Keith
[email protected]
@Out2Enroll
Out2Enroll
Out2Enroll