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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
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That's probably easiest. Health Affairs where health policy advances.
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Kathleen Haddad
Hello and welcome to another episode of Health Affairs This Week, the podcast where Health Affairs editors go beyond the headlines to explore health policy in depth. I'm Kathleen Haddad.
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Michael Gerber
And I'm Michael Gerber.
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Kathleen Haddad
June is Pride Month, and we devote today's episode to health equity issues impacting the LGBTQ community. Michael, a lot is happening to advance health equity for sexual minorities, and at the same time a lot is happening globally and domestically to stop the movement. Last week, Uganda joined Nigeria in passing a law calling for life imprisonment for anyone convicted of homosexuality.
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Kathleen Haddad
Aggravated homosexuality results in the death penalty. The health and safety of sexual minorities remains threatened in a host of authoritarian countries, including Russia. But we also have problems right here in the U.S.. Michael, you've been looking into restrictions on health equity at the state level. What have you found out?
00;02;12;08 - 00;02;37;16
Michael Gerber
Well, Kathleen, sadly, there's too much to talk about on just one podcast. But the latest news on this front is probably that just this week, a federal judge slammed a new Florida law that had banned, quote, puberty blockers for minors, saying that, the judge said that gender identity is real and therefore patients, and in the case of minors, also their parents and their physicians should be able to make decisions about appropriate care.
00;02;37;18 - 00;03;02;27
Michael Gerber
It was just an injunction, basically pausing the enforcement of the law just for the three minors involved in the lawsuit. But he also indicated that he thought the law would likely eventually be found unconstitutional, according to the AP, Florida is just one of 19 states with laws restricting or banning treatment for transgender minors. Many of which haven't gone fully into effect yet.
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Michael Gerber
They also say about 11 states plus the District of Columbia, have passed laws explicitly protecting gender affirming care. As I said, the judge's ruling is just a temporary injunction and the state of Florida has actually already come out and said that they will continue to enforce the law, just not against the three individuals currently involved in the lawsuit.
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Michael Gerber
It's not clear when the case itself will be heard or when it will be decided, nor when we'll hear from the same judge who only a few weeks ago presided over a trial involving several transgender adults and children suing the state of Florida for an earlier ban on Medicaid coverage for gender affirming care. With similar cases happening in other states as they pass laws, I can imagine, I'm no legal expert, that it's only a matter of time before some of these cases get decided and probably move up into the appeals court or maybe even eventually the Supreme Court has to weigh in.
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Michael Gerber
Meanwhile, the Human Rights Campaign this week declared a national state of emergency for LGBTQ+ people for the first time. According to the HRC, these bills are just some of more than 500 that they describe as attacking the LGBTQ community and have been introduced in state legislatures in the current session alone and almost half of those specifically target the transgender community, with more than 70 of those bills becoming law.
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Michael Gerber
As I said, we'll start to hear more of this from the courts pretty soon. While some of these laws explicitly talk about health care, others don't. But it's a reminder that even laws that don't always seem directly related health care, such as those, for example, about marriage, can impact one's health, and also that the LGBTQ community needs to be a focus of health equity efforts.
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Michael Gerber
Kathleen, I know you've edited a few Health Affairs papers on those topics recently, so what did you find out?
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Kathleen Haddad
First of all, there is a lot of heterogeneity in the community and so but still, most sexual minorities are at risk, increased risk of preventable chronic illness, mental illness and substance use and injury and mortality. And of course, the risk is higher for people of color. Just this month, we looked at how health insurance coverage has improved for the LGBT community.
00;05;22;11 - 00;05;54;19
Kathleen Haddad
Adults specifically who had lower coverage in 2013 before the Obergefell Supreme Court decision that legalized gay marriage and before the ACA. And then after these two policies took effect, the LGBTQ community adults had higher rates of coverage. And so I think that's a piece of good news along with some of the judicial perhaps protections that you talked about, Michael.
00;05;54;21 - 00;06;27;14
Kathleen Haddad
But, you know, there's also the situation with disabilities. The LGBTQ community has disabilities at twice the rate of other adults. And we published a paper on that last October in our disability issue. So I think this research that we're talking about is very hard earned because good data on sexual minorities is very scarce. So I understand, though, that there are some promising developments in this area.
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Kathleen Haddad
Michael, I think you've taken a look at that.
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Michael Gerber
Right. Yeah, it's definitely the case that, you know, we don't get probably as much research in this area because we just don't have the data to look at it. And we know without that data, it's hard to know exactly what the challenges are and then also hard to know whether solutions are working or not. For the most part, I think it's pretty clear that health care data in this country hasn't systematically collected information on sexual orientation or gender identity.
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Michael Gerber
You know, when I fill out forms for the doctor's office, it's only recently that sometimes there's another option besides male or female, that even those are usually pretty limited. We actually ran a Health Affairs Forefront article just a week or two ago by ICF's John Auerbach and the University of Miami's Claude Fox, where they said, we don't know much, for example, about mortality rates for the LGBTQ population because death certificates don't capture sexual orientation or gender identity.
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Michael Gerber
And even in situations where the data is collected, it's often in small samples that don't allow for the kind of extensive analysis we're getting used to in health care and health policy research. But they also, in their article, pointed out that the White House recently issued a report on gathering more evidence related to LGBT equity issues and, of course, recommended collecting that information more often.
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Michael Gerber
Additionally, agencies such as the Office of the National Coordinator for Health I.T., the CDC and others at the federal level have issued some guidance for what questions to ask and how to ask them so that we can maybe collect this information in a systematic way allowing for that larger research. Interestingly, they also point out that because of the continued fears of discrimination and stigma that, you know, providers and other researchers have to be careful when they're collecting this data, that it's not perceived as harassment or further worsening the stigma or fear of even seeking health care that sometimes impacts these communities.
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Michael Gerber
In other words, we really don't want to start asking the questions in a way that only worsens the problem and continues the legacy of health care providers, not always showing empathy or understanding to members of the community.
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Kathleen Haddad
So you mentioned your experience with providers in filling out forms and the two choices that exist often for gender providers have come a long way, but it's only been recently they've started to understand some of the health care needs of the LGBT community can be very different from the needs of non sexual minorities. I personally have some experience with this as the parent of a transgender child.
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Kathleen Haddad
If you remember ten years ago what it was like going to the pediatrician and I'd have to strategize how to corral the doctor, the nurse, the secretary, or the person who drew the blood, each of them to, you know, explain how my child has a boy's name but is really a girl. As you can see, they just were confused.
00;09;45;29 - 00;10;19;29
Kathleen Haddad
But I saw recently how this is changing and how much easier it's become. It's as if the pediatrician's office has undergone some educational training from the secretary on through the physician. And I think that that's important to take note of the community of providers that provides specifically gender affirming care has been well developed. And for decades they've had evidence based medical guidelines.
00;10;20;01 - 00;10;49;24
Kathleen Haddad
These have been developed by organizations like the World Professional Association for Transgender Health, The American Society of Endocrinologists, and the American Academy of Pediatrics has come along with these guidelines as well. And many other organizations, including the AMA and the ACP. The new state laws of interrupted access to care for many transgender patients depending on what state they live in.
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Kathleen Haddad
So if you can imagine the anguish this creates for parents, their teens and in some cases some states, even adults who are personally affected.
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Michael Gerber
Yeah. Kathleen, hearing you talk about your experience, it's interesting. There is certainly a lot more guidance out there even at the federal level. If you look at the websites of the CDC or SAMHSA and others. There's a lot of pages of information for sexual minority populations, but also for health care providers themselves. There's training curricula, for example, on SAMHSA’s page, on behavioral health equity, specifically for clinicians and the needs of the LGBTQ community.
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Michael Gerber
It is interesting, though, to note that the guidance coming from the federal level and from state agencies can really flip. You can imagine, you know, some of these governors who have been involved in some of the laws we were talking about earlier are running for president. And the day after inauguration, some of these trainings and websites may be ceasing to exist anymore.
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Michael Gerber
And it's a real reminder, sort of the intersection of politics and health. Not that we always need a reminder, but how it can really impact some people on a daily level and whether they're getting care or what type of care they're getting. I also, you know, as a paramedic, I saw some of these efforts to educate clinicians myself.
00;12;23;29 - 00;12;47;16
Michael Gerber
I can think back 10, 20 years ago when I was full time clinician and I'm sure I didn't know the words to use or the questions to ask members of the LGBTQ community. But since then, I know I've been to national conferences and groups like even the National Association of VMS Physicians fairly consistently have education on these topics at their national conferences.
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Michael Gerber
I remember really well listening to a talk given by an emergency physician with a transgender child and the impact that had on me and other people in the audience. And I think, as you said, we're definitely seeing a lot more from these national organizations.
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Kathleen Haddad
Yeah. You know, it's interesting because I think these organizations are really the closest to the providers and they have a lot of sway with helping providers understand how they need to make changes to provide care in the general practice setting for sexual minority populations. I want to just share another example of how things have changed. Just three years ago, I think, you know, having looked at the SAMHSA website, there were only one or two residential treatment programs for mental health care across the country that would accommodate transgender youth.
00;13;44;28 - 00;14;13;22
Kathleen Haddad
Anyone who was not binary still had to room with a binary child. And you can imagine a teen who already is steeped in mental health problems, what that could do to them, and that's not going to be a comforting place even if the institution really wants to try to provide the care. There are more of these RTCs now who provide this kind of care, mental health care and in fact, rely on evidence based treatment.
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Kathleen Haddad
But again, some of these have been stopped in their tracks by some of the state laws.
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Michael Gerber
It's really interesting some of these state laws are specifically carving out that if people have already started treatment, they can continue it while some of them are not. And some of them it's a little confusing where physicians don't know if they can continue treatment or not. And I think that will be an interesting aspect of this, too, as to whether treatment has to be stopped.
00;14;41;07 - 00;14;43;08
Michael Gerber
That's already started and the impact that can have.
00;14;43;09 - 00;15;07;07
Kathleen Haddad
Absolutely. So, Michael, we've had a good conversation. I think we'll have to leave it there for today. A reminder to all our listeners to take a look at Health Affairs coverage of health equity for the LGBTQ community and for all minority communities. Check out a current issue for the article on how Obergefell and the ACA impacted access to health coverage.
00;15;07;09 - 00;15;18;09
Kathleen Haddad
Also, please leave us a review if you liked the show and please tell a friend and subscribe to Health Affairs This Week. Wherever you get your podcasts. Michael, Thank you.
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Michael Gerber
Thanks, Kathleen.