Los Angeles—The U.S. House of Representatives is considering legislation that would repeal important elements of the Affordable Care Act ( ACA ) and replace the ACA with The American Health Care Act ( AHCA ). In addition to scaling back federal subsidies that make health insurance more affordable and cutting federal funds for Medicaid, the latest version of the House bill includes an amendment authored by Rep. MacArthur that would allow states to seek waivers for many of the ACA's key consumer protections. These waivers would permit health plans to charge higher premiums for people with pre-existing conditions; exclude essential health benefits; and include annual and lifetime caps on coverage.
The latest version of the House bill would have a negative impact on LGBT people who have gained coverage through the ACA at a higher rate than non-LGBT people. LGBT people are also disproportionately more likely to have pre-existing conditions—like mental health conditions or HIV/AIDS—and could be charged more based on health status; lose access to needed health services altogether; or exceed annual or lifetime caps.
LGBT People Have Disproportionately Benefitted from the ACA
* Data from the Health Reform Monitoring Survey collected in June/September 2013 and December 2014/March 2015 indicate that the percentage of LGB adults without health insurance decreased from 21.7 percent to 11.1 percent in this time period, a larger decrease than was observed in the non-LGB adult population.
* The percentage of LGB adults under 64 years old who did not have health insurance in 2014 was significantly lower in states that adopted Medicaid expansion under the ACA, 12.5 percent compared to 20.0 percent, according to data from the CDC's 2014 Behavioral Risk Factor Surveillance System ( BRFSS ).
* Between the fourth quarter of 2013 and the second quarter of 2014, directly before the individual mandate took effect to the end of open enrollment, data from the Gallup-Healthways Well-being Index Survey show that the uninsured rate among LGBT adults fell from 22.0 percent to 17.6 percent.
Nearly One Million LGBT People Would Lose Coverage by 2026
When scoring a prior version of the American Health Care Act, the Congressional Budget Office ( CBO ) estimated it lead to higher uninsurance rates in the U.S. as a whole. Based on estimates from the CBO, we estimate that nearly one million LGBT adults would lose insurance by 2026 under the proposed changes to the ACA. Considering the disproportionate rate at which LGBT adults gained insurance coverage under the ACA compared to non-LGBT adults, it is likely that this figure may even be higher.
LGBT People Could Be Charged More for Pre-existing Conditions Which Could Make Coverage Unaffordable
Under the latest version of the House bill, states could allow health plans to charge more for people with medical conditions. Coupled with the House bill's smaller subsidies for health insurance than exist under the ACA, this could make coverage unaffordable. LGBT people are more likely to have certain pre-existing conditions than non-LGBT people — widely viewed as a consequence of social stigma and discrimination. For example:
* Men who have sex with men ( MSMs ) are about 6% of the US adult male population, but represent over 60 percent of the population living with HIV in the US as of 2013. An estimated one in six MSMs will be diagnosed with HIV over the course of their lives as compared to one in 51 men in the general population.
* Transgender people, especially transgender women of color, are more likely than cisgender people to be living with HIV. In the 2015 U.S. Transgender Survey ( USTS ), 1.4 percent of respondents reported they were living with HIV, which is five times the prevalence in the U.S. population ( 0.3 percent ). More than 27 percent of transgender women in needs assessment studies report that they are living with HIV.
* LGB individuals, especially women, report higher prevalence and earlier onset of disability.
LGBT People Could Lose Access to Needed Benefits and Hit Lifetime or Annual Spending Caps
Under the latest version of the House Health Care bill, states could eliminate requirements for essential benefits coverage, such as mental health care and substance use treatment, which would have a disproportionate impact on LGBT people who appear to have a higher need for such services due to disproportionate exposure to violence, harassment, rejection, and discrimination. States could also end the prohibition on lifetime or annual spending caps for insurance coverage, which are essential for people with chronic health conditions that require on-going medical treatment, like HIV/AIDS or mental health conditions.
* Research shows that mood, and anxiety disorders, attempted suicide, and self-harm are more common among LGB adults than non-LGB people. Studies also indicate that rates of depression, anxiety disorders, and attempted suicide are also elevated among transgender people.
* According to the 2015 U.S. Transgender Survey, 39 percent of transgender respondents experienced serious psychological distress in the month before completing the survey, compared with only 5 percent of the U.S. population.
* In addition, LGB people are more likely to report tobacco use, drug use, and alcohol disorders than their non-LGB counterparts.
The Williams Institute, a think tank on sexual orientation and gender identity law and public policy, is dedicated to conducting rigorous, independent research with real-world relevance.
