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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;00 - 00;00;35;03
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. A relatively recent but rapidly growing body of research, some published in Health Affairs, shows various health disparities between sexual and gender minority populations in the population as a whole. These disparities include insurance coverage, access to care and health outcomes. As data regarding this population grows, we're able to answer questions that historically were just out of reach.
00;00;35;05 - 00;01;03;17
Alan Weil
What are recent trends in coverage and access for lesbian, gay, bisexual and transgender people? That is the topic of today's episode of “A Health Podyssey”. I'm here with Andrew Bolibol, a Ph.D. candidate in the Health Policy Program at Harvard University. Mr. Bolibol and coauthors published a paper in the June 2023 issue of Health Affairs, examining trends in health insurance coverage among LGBT adults.
00;01;03;19 - 00;01;20;06
Alan Weil
They found a closing gap in health insurance among LGBT adults relative to non LGBT adults. But disparities in access persist. We'll discuss these findings in more detail in today's episode. Mr. Bolibol, welcome to the program.
00;01;20;08 - 00;01;22;04
Andrew Bolibol
Hello, and thank you for having me.
00;01;22;06 - 00;01;57;01
Alan Weil
Thanks for joining me today. So your paper sort of situates itself in, as I said at the outset, a growing but still relatively small body of research that's been conducted on the health status and coverage rates of LGBT adults. Maybe if you could just start by giving our audience a little bit more of the context than I was able to do. What have we known historically about health insurance coverage rates, access to care, health outcomes for LGBT folks?
00;01;57;03 - 00;02;04;08
Andrew Bolibol
So this really dates back quite a while, and it goes back to the employee retirement Income Security Act in the seventies that was
00;02;04;08 - 00;02;05;12
Andrew Bolibol
passed.
00;02;05;14 - 00;02;36;14
Andrew Bolibol
And under that act, the federal government took more control over how they regulated health insurance and how states were able to regulate it themselves. So we have, in the way we provide health insurance, most people in the United States get it through their employer. And unsurprisingly, a large percentage of those employers are what they call self-insured. And what self-insured means is essentially that the employer is on the hook for all claims and health risk of their employees.
00;02;36;16 - 00;02;59;20
Andrew Bolibol
So when an employer is self-insured, the way that they are regulated is through the federal government. So state regulations do not apply to these employers. And in addition to that, in the nineties, with the passage of the Defense of Marriage Act, it defined marriage as between a man and a woman. So excluding same sex couples and not legally recognizing same sex marriages.
00;02;59;23 - 00;03;25;21
Andrew Bolibol
And so this had the inadvertent effect of blocking access for health insurance for large swaths of people in same sex relationships because they cannot get it through their spouse or their partner. And this was driving the big, this really was what drove the gap in what we see in the early 2000s in terms of health care coverage between LGBT adults and non LGBT adults.
00;03;25;23 - 00;03;38;19
Andrew Bolibol
And it wasn't really until the 2010s, later 2010s, that we had a few policy changes that really impacted how LGBT folks were able to get coverage.
00;03;38;22 - 00;03;58;16
Alan Weil
So what you're describing is in a world where most people get coverage through employment, or dependents of someone who's employed, in a same sex couple that's not recognized legally and not recognized by the employer. One member of that couple, if they're not working, is not going to be able to get coverage through the other,
00;03;58;16 - 00;04;22;05
Alan Weil
whereas in the same sex marriage that would be available to them. And that creates a missed opportunity to provide coverage that would exist in other circumstances. So that's sort of the history of why coverage rates were lower for LGBT folks. Is that a reasonable telling of the story?
00;04;22;07 - 00;04;47;06
Andrew Bolibol
Yeah, that's correct. And additionally, in terms of public insurance programs, so programs like Medicaid, they're, before Medicaid expansion which I'll talk about in a bit; people, especially LGBT adults, didn't often have dependents. So that's how they would normally qualify for Medicaid. Not based on just income alone. So they were unable to access public insurance programs as well, which also drove part of this disparity.
00;04;47;08 - 00;05;03;27
Alan Weil
Right. So that's I'm glad you brought that up. So we have sort of both public programs and private coverage with these disparities, if you will, built into them. Can you say a little bit about how that translated then into access or health outcome disparities as well?
00;05;03;29 - 00;05;27;07
Andrew Bolibol
So in terms of access to care, obviously the kind of, I guess, basic answer is that it definitely dampens access to care. So if you think about how people who are uninsured are able to or were able to access care, it's usually through charity care, federally qualified health centers and in those in themselves, present barriers to access already.
00;05;27;10 - 00;06;04;15
Andrew Bolibol
When people are faced with actually paying the full cost of care, they typically don't. We know that uninsured folks typically pay about up to maybe 40% of the care that they receive as uncompensated care. So it really drives disparities in terms of accessing just normal preventive services like mental health services, prescription drugs, your annual checkup. Those are things that are often forgone because of this issue of not having health insurance and providers not willing to take individuals without insurance, which then translates to worse health outcomes for LGBT folk because of this gap in coverage.
00;06;04;17 - 00;06;21;17
Alan Weil
So in your study, you start looking at changes in coverage over a recent period and maybe you can simultaneously say what the periods are and you can explain what the policy environment was in each of those three periods and how they differ.
00;06;21;19 - 00;06;45;15
Andrew Bolibol
Yeah, so we divided into three different time periods and we call it the pre ACA, which is 2013, early ACA, which was 2014 to 2017, excuse me, 2016, and then the late ACA, which was 2017 to 2019. And we did this for a few reasons. So 2013 was before the major provisions of the Affordable Care Act, the ACA, came into effect.
00;06;45;17 - 00;07;14;12
Andrew Bolibol
It was also the start of the beginning of recognition at the federal level of same sex marriages in 2013. This is before legalization of same sex marriage across the country. It was United States v Windsor, and in that case the Supreme Court overturned Section 3 of DOMA and, DOMA being the Defense of Marriage Act, and what that did was that it allowed states to legally recognize same sex couples as married.
00;07;14;15 - 00;07;52;17
Andrew Bolibol
So it legalized marriage in those states that had passed ordinances or laws that legalized same sex marriage. However, it didn't overturn, that case did not overturn Section 2 of Domo, which meant that states that did not legally recognize same sex marriage did not have to recognize same sex marriages in other states that did allow it. So, for example, if I got married, a same sex couple in a same sex marriage, in Massachusetts, and then I move to Alabama, Alabama would not have to recognize my marriage because they had not passed anything related to same sex marriage or in some cases explicitly defined marriage as between a man and a woman.
00;07;52;20 - 00;08;33;18
Andrew Bolibol
So that was the beginning of this kind of change in terms of the biggest barrier to access, which was getting coverage through a spouse who was working and got their coverage through their employer in the middle period or the early ACA period, 2014 2016. That encompasses the, one, the Medicaid expansions in the marketplaces of the Affordable Care Act, which extended access to not just LGBT Americans, but a whole swath of Americans, especially through Medicaid expansion and some other work has shown that Medicaid expansion has significant effect for LGBT coverage in states that did expand it versus states that did not expand it.
00;08;33;20 - 00;09;09;09
Andrew Bolibol
And also, during this time, Obergefell v Hodges, which is the probably more famous case, which is when the Supreme Court ruled legalization of same sex marriage across the United States. So all states, whether they had laws on the books, recognizing or not, had to recognize same sex marriages and allow same sex marriages across all the states. And this time period, we what we chose as like the kind of the beginning of the end of barriers to at least through to marriage, which is a way to access health insurance for many folks.
00;09;09;12 - 00;09;37;27
Andrew Bolibol
And it also started this would allow us to see like a start of a different trend in coverage for these folks. And then we chose our last period, 2017 to 2019, because we figured that that was probably the period we see the most impact if there was any impact from both the ACA and the Supreme Court ruling where we could see changes in coverage and access if there were any changes to see and how those rulings may have implications for coverage.
00;09;38;00 - 00;10;02;16
Alan Weil
So this is a really dynamic policy period that you're looking at. And what's striking to me as you describe it is there changes that would affect private coverage and there changes that would affect public coverage. And between the two of those, you could definitely expect to see some something happening. And that's exactly what you looked at. I want to now get to the punch line and find out what it is you observed.
00;10;02;19 - 00;10;42;13
Alan Weil
But I'm going to say we'll do that after we take a short break and we'll have that conversation then. And we're back. I'm speaking with Andrew Bolibol about health insurance coverage and access to care among LGBT adults in the period 2013 to 2019. Before the break, we heard about the dynamic policy environment during that period. So let's jump straight to the findings.
00;10;42;14 - 00;10;52;10
Alan Weil
What did you find about changes in health insurance coverage during this period that may or may not line up with all the policy shifts we saw happening?
00;10;52;12 - 00;11;35;09
Andrew Bolibol
So quite shockingly, at least it was it was shocking to me is that over this time period from the beginning for 2013, Maria noticed a very large gap in health insurance coverage for LGBT folks relative to non LGBT folks, is that that gap completely closed by the end of our study period. So by the end of 2019. And even the insurance coverage for LGBT folks passed surpassed that of non LGBT folks during this time period, which is kind of incredible given that it was a relatively short time period and they saw in the LGBT community a huge gains in health insurance coverage, which was driven particularly by private insurance coverage as opposed to public
00;11;35;09 - 00;11;38;04
Andrew Bolibol
insurance. At least in our data.
00;11;38;06 - 00;11;59;07
Alan Weil
Well, that's a pretty big finding. And I think it's notable that it is a short time relative to how long the preexisting patterns had been in place. You did have some interesting subgroup findings, and I wonder if you could describe some of those, because one in particular certainly jumps out and I think would be of great interest to our listeners.
00;11;59;09 - 00;12;37;28
Andrew Bolibol
Yeah. So very much related to the Obergefell ruling and the Defense of Marriage Act is the fact that partnered LGBT folks saw the largest gains in health insurance coverage relative to non partner and LGBT folks, and more so than their non LGBT partner counterparts. And that's perhaps not surprising given that same sex was legalized. Same sex marriage was legalized in 2015 and that opened a door for many people to gain access through their partner when through marriage.
00;12;37;28 - 00;12;51;17
Andrew Bolibol
And so I think that was probably one of the most powerful findings, is that the Supreme Court ruling probably had large implications for the gains in coverage for LGBT folks, especially partnered LGBT folks.
00;12;51;19 - 00;13;10;06
Alan Weil
Yeah. Now, of course, this wasn't an experiment, so we can't say A cause B, but the direction and timing is sure indicative of this making a real difference. I thought that was quite interesting. But then you also looked at access to care and barriers to access. What did you find there?
00;13;10;09 - 00;13;31;25
Andrew Bolibol
So in terms of access to care and barriers to access, there were as there was in health insurance coverage, large gaps in terms of access and utilization of care. So things like going to or having a primary care physician or provider, having usual source of care, prescription drugs, mental health and the cost issues associated with that.
00;13;31;28 - 00;13;58;27
Andrew Bolibol
And so over the time period, we saw those gaps between LGBT folk and non LGBT folks closed. And so there was less issues of utilization and access. But unfortunately, in the last or towards the end, there's still the gaps still persist. So LGBT folks still have a relatively more difficult time accessing and utilizing health care despite the fact that they have higher rates of insurance coverage now.
00;13;59;00 - 00;14;14;04
Alan Weil
So that seems a bit of a policy conundrum. You think that the primary tool we use to assure access to care is insurance. You close the gap in the one, but it doesn't close it in the other. What do we think is going on here?
00;14;14;06 - 00;14;44;10
Andrew Bolibol
There's several explanations that could be plausible. And again, like you referenced earlier, this wasn’t an experimental set up. So we can only kind of hypothesize what's driving this. And so there's what we thought is two things. And one of those is if LGBT folk in the marketplace for the Affordable Care Act marketplace are differentially choosing high deductible health plans, then that would in and of itself present a cost issue.
00;14;44;13 - 00;15;09;08
Andrew Bolibol
And it's not out of the ordinary to think that. I think given the wide swath of literature that we know about how individuals behave when they're faced with a very complex health insurance contract is they don't behave the way theory might predict, neoclassical theory might predict. So it's not necessarily surprising that in that case, they would face cost issues for a high deductible health plan.
00;15;09;10 - 00;15;34;12
Andrew Bolibol
And another one that's really important to point out, and we don't have necessarily we weren't able to dive into this, but I think other literature has looked at it is the fact that discrimination and bias drive barriers to care. Those in and of themselves can prevent a lot of people from seeking care. We know from other identities that race concordance with providers matters a lot for people seeking medical care.
00;15;34;14 - 00;15;43;16
Andrew Bolibol
So that could also be the case for LGBT folk and why they face these still issues in accessing and utilizing care.
00;15;43;19 - 00;16;06;07
Alan Weil
Right. So we think, okay, if we give someone an insurance card, it will close these gaps. And there's no question it's helpful. But as you note, it doesn't address all of the potential barriers, whether it has to do with financial barriers that remain when you are insured or other barriers to access. So this leads me to wonder sort of what comes next.
00;16;06;08 - 00;16;36;11
Alan Weil
You noted and I was I echoed the rapidity with which we close this coverage gap. My guess is that there's no similarly rapid mechanism that we can employ to close some of the gaps in access and ultimately in health outcomes. But as you think about what was accomplished during this period, I wondered where it leads you in terms of thinking about additional policies that might make a difference here.
00;16;36;19 - 00;17;07;25
Andrew Bolibol
There's two parts to this question. I think a lot more research needs to be done causally identifying why LGBT folk actually face these barriers to access. I gave a couple of hypotheses, but we don't really know why there's such difficulties for folks in obtaining care. We can only hypothesize. And so I think that is a really fruitful one, a fruitful area for research that really needs to be done and that really has is tied to policy implications.
00;17;07;27 - 00;17;41;18
Andrew Bolibol
I think that in the States, or rather the what we kind of know is that the states that have significant protections for LGBT folk, the states that you might assume, LGBT folk fare better in terms of health outcomes and access to health. So things like banning religious exemption laws matter a lot for health insurance coverage and anti-discrimination laws in public assistance matters a lot in terms of how LGBT folk can access care or even get health care coverage.
00;17;41;21 - 00;18;03;20
Andrew Bolibol
And so I think those two things are really important and will continue to be important. I think this is, for better or worse, at the front of the news in a lot of areas is health access, especially for transgender individuals in the United States and the LGBT community isn't a monolith. We're all very different and have different and unique health needs.
00;18;03;20 - 00;18;30;01
Andrew Bolibol
And I think because of that, lumping them all together like we did isn't necessarily indicative of what how the community is moving as a whole. Some might fare better than others. And so I think that for policy reasons, that means that we really need to focus on what are the unique needs of each type of individual in this community and how we can better meet those needs.
00;18;30;04 - 00;18;39;20
Andrew Bolibol
And I think this is a conversation not just happening about with LGBT health care, but also across many different identities, such as race and ethnicity.
00;18;39;22 - 00;19;08;00
Alan Weil
So I'm really glad you brought the conversation around to this point. And maybe it's worth telling our audience why you did group LGBT together and you stop at the ‘T’ in this study, because I think there is often a tendency in these kinds of large data set quantitative analysis to find a result and think of the group that is studied as one as opposed to many individuals with variety.
00;19;08;02 - 00;19;17;18
Alan Weil
So can you just say a little bit more about sort of the data limitations and why this group and why not differentiating within it?
00;19;17;20 - 00;19;46;00
Andrew Bolibol
Yeah, and thank you for allowing me to speak on this. So it was really just a limitation of the data, the way that the Health Reform monitoring survey, which is what we the data that we use, the way they ask the question is they collapse it into one and it's lesbian, gay or bisexual or transgender individuals. So that's why the other parts of the acronym, like the Q, I, A, are not there because they don't actually ask questions related to those identities.
00;19;46;02 - 00;20;19;09
Andrew Bolibol
So we can't necessarily say anything that an individual answering that might be intersex or asexual or any other type of identity that normally we associate with the LGBT community. And further, they didn't just aggregate the LGBT question, so it wasn't this percentage identified as lesbian, this percentage they identified as gay, so on and so forth. So we just had to make that make the best with what we had, which was just the question relating to any type of identity related to LGBT.
00;20;19;16 - 00;20;32;01
Andrew Bolibol
And that's how we proceeded. But I think, again, going back to that to that point is not necessarily optimal because there is such heterogeneity within the community and it has different policy implications.
00;20;32;03 - 00;20;50;05
Alan Weil
Right? And we do a lot of this in our work where, you know, you, you, you study what you can with what you have and it opens up the door to other questions that you may need different methods or different data sets to try to answer. Well, as we come to a close. If I may, I'd like to ask you, you are a Ph.D. candidate.
00;20;50;06 - 00;21;01;06
Alan Weil
I wonder if you can say a little bit tied to this work and some of the questions we were just talking about. Where is your own research agenda headed?
00;21;01;08 - 00;21;32;18
Andrew Bolibol
So I've actually pivoted a little bit. I'm very interested in the intersection of health and crime. I was doing a little bit work of work on a randomized controlled trial of health care provision within the jails in the United States. And I think there is there's an element of kind of this this paper and this research in that as in the general population, there are significant disparities within our carceral system, particularly for LGBT folk, but also racial and ethnic minorities.
00;21;32;20 - 00;22;04;12
Andrew Bolibol
So that's kind of the future where I see the direction of my research going. I think in terms of the area of LGBTQ health coverage and health outcomes, it is a really small area, but it's growing and I think there's a lot of great work being done in that area. I still want to continue somewhat in that vein, but I pivoted a bit and just in terms of my interest in probably the most vulnerable population in the United States, which is justice involved individuals.
00;22;04;15 - 00;22;31;21
Alan Weil
Well, Mr. Bolibol, thank you for explaining that and talking about your upcoming priorities. I agree with you about the vulnerability of that population. It's nice to see expanding knowledge about this population as well. And we are happy at Health Affairs to be part of the outlet for that increased knowledge that we have. Thank you for being my guest today on “A Health Podyssey”.
00;22;31;24 - 00;22;37;06
Andrew Bolibol
Thank you so much for having me.
00;22;37;08 - 00;22;41;00
Alan Weil
Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend.
00;22;41;03 - 00;22;42;11
Alan Weil
About “A Health Podyssey”.