the affordable care act: building health equity for lgbt people kellan baker, mph, ma out2enroll...
TRANSCRIPT
The Affordable Care Act: Building Health Equity for
LGBT People
Kellan Baker, MPH, MAOut2Enroll Steering Committee
Learning ObjectivesBy 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 people2. Identify strategies for the outreach and enrollment of
LGBT people into health care under the ACA3. 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 PeopleFaces 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 QuestionWhich of the following is not a term describing sexual orientation?
a) Straight b) Transgenderc) Heterosexual d) Lesbian
Polling QuestionHow many people in the United States identify as LGBT?
a) 700,000b) 1.3 millionc) 9 milliond) 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 DisparitiesHomelessness
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
Q3 2013 Q4 2013 Q1 2014 Q2 20140%
5%
10%
15%
20%
25%
30%
24.20%22.00% 23.70%
17.60%17.20% 16.70%15.00%
13.20%
LGBTNon-LGBT
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 QuestionWhat types of health care can be blocked by transgender insurance exclusions?
a) Preventive screenings like a mammogramb) Hormone therapyc) Treatment for pneumonia, a broken arm, or a heart
attackd) SRSe) All of the above
BUT: Change Is Happening!Medicare removed its exclusion in 2014Federal guidance requires plans to cover preventive
screenings for trans peopleACA 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 LGBT-friendly events, like LGBT Pride fairs
Find this and other graphics on Out2Enroll’s
Facebook page and www.out2enroll.org
Out2Enroll
OUT2ENROLL Graphic
OUT2ENROLL Graphic 2
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: MariaAt 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 togetherb) If they are married c) If they file federal taxes togetherd) What state they live in
Case Study #2: JimmyJimmy 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 thatb) Make a note that Sam identifies as femalec) Consistently refer to Sam as “she” in the futured) 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/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): http://strongfamiliesmovement.org/lgbt-health-care-guide
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/moving-the-needle/
LGBT Health Training: The National LGBT Health Education Center www.lgbthealtheducation.org
