Healthcare and Health Insurance for LGBTQ+ People

Most LGBTQ+ people today have access to health insurance through the Affordable Care Act Marketplace, Medicare, Medicaid, and other sources. Yet a significant number still can't afford the care they need. People seeking gender-affirming care, in particular, run into challenges, such as whether it is covered and how much it costs. Here's a guide for LGBTQ+ Americans trying to navigate the process of obtaining health insurance and receiving proper care.

LGBTQ+ Healthcare History

Over time, the environment for LGBTQ+ healthcare has improved—partly thanks to increased acceptance of LGBTQ+ Americans.

In 2010, the federal Affordable Care Act (ACA) made it illegal for health insurers to discriminate against LGBTQ+ Americans. Before the ACA became law, health insurers could deny coverage to LGBTQ+ people or charge them higher rates. In the wake of its passage, uninsured rates among LGBTQ+ people dropped by almost half.

In addition, before the Supreme Court made same-sex marriage legal across the U.S. in 2015, many same-sex partners could not access group health insurance plans via legal spousal coverage. Now, any insurance company offering health coverage to opposite-sex spouses must provide the same coverage for same-sex spouses as long as the couple is legally married.

More recently, additional federal laws have expanded access to health insurance for LGBTQ+ people. For example, most health insurers today say that some or all medically necessary treatment for gender dysphoria is covered, according to the organization Out2Enroll; the prior exclusions were banned by a 2016 regulation to implement the Affordable Care Act's Section 1557. 

Healthcare Disparities in the LGBTQ+ Community

Despite the progress, however, disparities still exist in access to healthcare. LGBTQ+ people are slightly more likely than non-LGBTQ people not to have health insurance and more concerned about being able to pay medical bills. A study published in 2023 in the journal Health Affairs found LGBTQ+ adults were more likely than others to go without healthcare due to the cost of care. 

Another study showed they're less likely to have a regular healthcare provider and more likely to report experiencing inadequate medical care or a delay in getting care.

In a 2022 survey, 12% of LGBTQ+ Americans said that a health insurer had discriminated against them based on gender identity, sexual orientation, or both. Among those experiencing such discrimination are people seeking gendering-affirming care. In 10 states, for instance, the joint state and federal Medicaid program for low-income Americans won't cover transgender-related care for patients of any age and in an additional three states Medicaid won't cover it for minors.

Some private health plans also deny coverage to transgender people for certain healthcare services, using exclusions such as "services related to sex change" or "sex reassignment surgery."  

Health Issues the LGBTQ+ Community Faces

Among the major healthcare challenges still faced by LGBTQ+ Americans today are these:

Costs and Availability of Gender-Affirming Care 

The cost of transgender-specific care can range from $25,000 to $75,000, according to one widely published estimate. 

Most health insurers generally cover medically necessary gender-affirming care, including gender-affirming surgery and hormone treatments. But 23 states have enacted bans on medication or surgical care for transgender youth, and five states make it a felony to provide such care.

Mental Health and Substance Abuse

LGBTQ+ people are more likely than their non-LGBTQ+ counterparts to have a mental health condition such as depression, anxiety, or suicidal thoughts. In addition, LGBTQ+ adults are more likely than others to experience a substance abuse disorder.

Cancer Risks

Lesbian and bisexual women may be at a higher risk of developing breast, cervical, or ovarian cancer than heterosexual women due to less-frequent screening. Other risk factors include smoking, alcohol consumption, delayed childbirth, or not having children. Other LGBTQ+ populations may have other unique cancer risks due to delayed screening, smoking and alcohol use, and HIV or HPV infection. 

HIV

​​Almost 70% of new HIV diagnoses in the U.S. are among adult and adolescent gay and bisexual men, according to the CDC. Pre-exposure prophylaxis (PrEP) medication can help prevent contracting human immunodeficiency virus (HIV) and/or acquired immunodeficiency syndrome (AIDS). As of July 2021, the U.S. government began requiring all individual and group health insurance plans to cover PrEP and services related to PrEP without any copays or coinsurance required.

Fertility Treatment

LGBTQ+ people who want to start a family may face more challenges in accessing fertility services, which aren't usually covered by health insurance plans. In addition, LGBTQ+ people may not qualify for services under insurance plans' requirements and definitions around "infertility."

Access to Care for LGBTQ+ People: Other Issues

Although the percentage of uninsured LGBTQ+ people dropped by almost half after the ACA's passage, access to care remains a problem for a variety of reasons.

In addition to the state bans discussed above, 10 states allow healthcare professionals to deny service to LGBTQ+ patients, based on the providers' religious beliefs.

A 19th News/SurveyMonkey poll conducted in 2022 found that, compared with non-LGBTQ+ patients, significantly more LGBTQ+ patients reported feeling discriminated against at doctor's appointments because of their gender or sexual orientation (20% vs. 3%). More than twice as many (16% vs. 7%) said they had been denied or refused medical treatments.

As a 2021 report from the U.S. Department of Health and Human Services noted, "LGBTQ+ individuals may have difficulty finding LGBTQ‐friendly providers," and their negative experiences with the healthcare system "can translate into patients feeling fearful or [having] levels of mistrust in disclosing their sexual orientation or gender identity to providers and otherwise advocating for their own healthcare needs."

By contrast, the report added, "when providers demonstrate knowledge of, and sensitivity about, their community and concerns, LGBTQ+ patients are more likely to establish effective therapeutic alliances."

Understanding Your Rights

LGBTQ+ people have rights under both federal law and some state laws. For example, 15 states and the District of Columbia ban health insurance discrimination based on sexual orientation or gender identity, while 24 states and the District of Columbia protect transgender people against discrimination in health coverage.

The Affordable Care Act, as mentioned earlier, prohibits health insurance marketplaces and the plans sold within them from discriminating based on sexual orientation or gender identity. As a result:

• Health insurers can't charge higher premiums if you have a pre-existing condition like HIV/AIDS or simply because you're part of the LGBTQ+ community.
• Health insurers must offer the same coverage to same-sex and opposite-sex spouses.
• Health insurance marketplaces must treat married same-sex couples the same as married opposite-sex couples when it comes to receiving premium tax credits and lower out-of-pocket insurance costs.

The Bottom Line

LGBTQ+ Americans have much the same access to health insurance as other Americans do, thanks largely to the Affordable Care Act. However, some LGBTQ+ patients report being discriminated against by health insurers or providers. And several states have passed or proposed laws enabling health insurers to deny coverage of gender-affirming care. As such, true equality remains a goal rather than an accomplished fact.