Photo Credit: The Gender Spectrum Collection
On Tuesday, the U.S. Supreme Court declined to expedite review of Texas v. California, the politically-charged Health Care Repeal Lawsuit backed by the Trump administration and initiated by a cohort of Republican attorneys general that seeks to overturn the Affordable Care Act (ACA). The move followed a ruling by the 5th U.S. Circuit Court of Appeals last month that found the ACA’s individual mandate unconstitutional. But rather than repealing the entire law, the 5th Circuit asked Judge Reed O’Connor, the trial judge who had initially struck down the entire law, to redo his analysis. With the case likely to return to the high court, the future of the ACA remains unclear. What is not unclear is that if the ACA is repealed, it would harm the health and well-being of LGBTQ+ people and people living with HIV (PLWH) who have disproportionately benefited from the ACA’s provisions.
Some provisions of the ACA that have been especially vital for LGBTQ+ people and PLWH include:
- Protections for those with pre-existing conditions. The ACA requires that insurance companies provide insurance to everyone who applies at comparable rates, regardless of pre-existing conditions, including HIV. Prior to the ACA, it was common for PLWH to either be denied insurance coverage for having a pre-existing condition or to be offered plans with exorbitantly high premiums and prohibitive spending caps. The ACA prohibits discrimination in insurance coverage based on pre-existing conditions, and it also eliminates annual and lifetime spending caps. Both of these reforms have resulted in increased access to health insurance coverage for PLWH. This is critically important for helping PLWH adhere to treatment and maintain viral suppression.
- Medicaid expansion. Medicaid expansion has been extremely helpful for expanding coverage to low-income LGBTQ+ people and PLWH who previously could not qualify for Medicaid. The Center for American Progress found that in states expanding Medicaid, 386,000 uninsured low-income LGBTQ+ people became newly eligible for Medicaid.
- Essential health benefits. The ACA’s required coverage of essential health benefits—including preventive services like HIV/STI screening, prescription drugs, and mental health and substance use treatment—has been especially important for LGBTQ+ people. Research has shown high rates of behavioral health burden and substance use disorder among LGBTQ+ populations. Required coverage for these essential health benefits is essential in order to reduce these disparities.
- Nondiscrimination provisions. Section 1557 is the nondiscrimination provision of the ACA. In 2016, the Obama Administration released a final rule implementing Section 1557. This rule explicitly prohibited discrimination on the basis of gender identity in health care programs receiving federal funding. It also explicitly prohibited discrimination against intersex and non-binary individuals. The final rule also prohibited insurance companies from imposing blanket exclusions for gender affirmation treatments, and it prohibited some forms of sexual orientation discrimination that constituted sex stereotyping. Unfortunately, this rule has been under attack since it was finalized, and the Trump administration recently released a new proposed rule that would remove the gender identity and sexual orientation protections. The ACA nondiscrimination provisions are extremely important for improving access to care for LGBTQ+ people, who experience widespread discrimination in health care. Both past experiences of discrimination and anticipation of future discrimination in health care—which can include microaggressions, verbal and physical harassment, and denial of service—prevent LGBTQ+ people from seeking necessary and preventative medical treatment.
The ACA has been critical for expanding access to health care for all Americans across the board, but this is especially true for populations who traditionally experience lower rates of insurance coverage and disparities in health outcomes, including LGBTQ+ people and PLWH. Repeal of the ACA could have devastating consequences for the many LGBTQ+ people and PLWH who only have access to life-saving health care through the ACA. We must raise our voices to protect the ACA and the millions of Americans who stand to lose coverage if it is repealed.
Tim Wang, MPH, is the Senior Director of Health Policy at The Fenway Institute