The Affordable Care Act (ACA), commonly known “Obamacare,” was passed into law in March of 2010. Since then, the ACA has brought criticism and concern from both ends of the political spectrum as well as significant confusion to the American public on what exactly they can expect when the ACA goes into full implementation on Jan. 1, 2014. The ACA will have an effect on all Americans, but perhaps most significantly with sub-populations that are currently underserved, including the LGBT community.
Within our current healthcare system, the LGBT community faces several significant barriers to equal treatment and insurance coverage. Some insurance company policies regarding pre-existing conditions as well as lifetime coverage limits put individuals with chronic diseases such as HIV/AIDS and mental health conditions at a disadvantage to receive critical regiments of care.
Additionally, the lack of non-discrimination policies within some health insurance carriers, hospitals and other medical facilities can create unnecessary lapses in coverage and in some cases refusal for treatment based on sexual orientation or gender identity.
“I am concerned there might be a limitation of resources and providers for services,” says Dr. Rafael Pinero of Pinero Preventative Medical Care in Orlando. “For the LGBT community, I think there should be more providers sensitive to their needs.”
The Center for American Progress in Washington D.C. has been analyzing the potential effects of the ACA on the LGBT population since the first drafts of the bill have been available. It identified seven determinants to equal healthcare within the LGBT community, including lack of LGBT-specific data, relationship recognition by the government, legal gender recognition for transgender individuals, poverty, homelessness and general discrimination.
To begin to combat these healthcare determinants within the LGBT community, in April 2010 President Barack Obama and Secretary of Health of Human Services Kathleen Sebelius tasked the Department of Health and Human Services (HHS) to identify steps HHS could take to improve the health and well-being of the LGBT community under the ACA. In a report released in July 2013, HHS outlined several achievements in care within the LGBT community.
The achievements included the implementation of data collection policies from Federal and State agencies regarding patient gender identity and sexual orientation. Several LGBT-based survey questions have been developed and are currently being tested by HHS as well as the Center for Disease Control’s National Health Interview Survey. The first results of this significant data collection will be available in 2014.
Additionally, HHS has set in place a policy for all HHS and ACA medical providers that no patient can be denied benefits or services based on among other categories, gender identity and sexual orientation.
While the actual effects, both positive and negative, of the ACA on the LGBT community will not be fully understood until a few years after implementation, it is well-believed that the effects will be positive.
“With the new healthcare laws, I see more opportunities for our LGBT community to receive more comprehensive health care services,” says Dr. Pinero.
Advantages to LGBTs
One of the most significant advantages of the ACA to the LGBT community will be seen within the prohibition of insurance companies to deny coverage based on pre-existing conditions. This will allow individuals with HIV/AIDS not only insurance coverage, but more comprehensive coverage to best manage their overall health. Under new provisions, HIV/AIDS medications are also expected to be more affordable. The ACA will support the development and funding of patient centered health homes for people with HIV/AIDS to ensure continuity and quality of care for those most severely affected.
In our current healthcare system, identifying as transgender has been considered a pre-existing condition. This designation makes healthcare unavailable for many in the transgender community.
“Regarding transgender patients, there are presently limitations regarding the coverage for medical and psychological therapy needed during their transition,” says Pinero.
This will no longer be the accepted designation under the ACA. Transgender individuals will now have access to mandated culturally competent care and cannot be refused treatment based on gender identity. However, there are still several details of the ACA needing clarification regarding transgender patient care.
“It is yet to be seen exactly what the new healthcare plans will cover for transgender individuals in regard to hormone therapy treatments and what essential services of the transition process will be covered,” explains Andrew Cray, policy analyst with the Center for American Progress.
Private insurance isn’t untouched
For Americans with private insurance plans through their employers or other means there will be a number of changes. The ACA will require all private health plans to become an HHS-approved “Qualified Health Plan.”
The two purposes of these plans is to ensure that comprehensive and effective insurance policies are being sold to consumers. Additionally, essential benefit packages will require a clear and understandable explanation of benefits through the policy. Qualified Health Plans are structured in 10 categories of care to ensure all health needs are met through the policy. These 10 categories are: ambulatory care (outpatient services and doctor’s appointments), emergency services, maternity and newborn care, emergency services, mental health and substance abuse services, prescription drugs, rehabilitative services, laboratory services, prevention services and pediatric services including oral and vision care.
The effect of this more complete insurance package, however, is a higher cost for employers which can then equate to a higher premium for employees. This was in fact confirmed on July 30, 2013, when Florida Insurance Commissioner Kevin McCarty told the State Health Insurance Advisory Board that on average business insurance rates will rise anywhere from 5% to 20% and individual plans are expected to increase 30% to 40%.
Of concern to small business owners is the new requirement to provide health insurance for their employees. The ACA requires all businesses with 50 or more full time employees to provide employees with health insurance options. Some small business owners have voiced their concerns about their ability to pay premiums for employee coverage and as a result be forced to cut their staff either to be able to pay insurance premiums or to decrease their total employees to a number below 50. Either scenario presents unfavorable unemployment outcomes for the employee and the State and Federal unemployment rates. Businesses with less than 50 full time employees will not be required to provide insurance but if they should chose to do so, will be eligible for federal tax credits.
The ‘centerpiece’ option
For Americans not receiving coverage through their employers, a plan will need to be purchased through what is described as “the centerpiece” of the ACA, the Health Insurance Marketplace.
“Individuals needing insurance plans can go to Healthcare.gov beginning on Oct. 1, 2013 to see what plan option is best suited for them and available to them in their state,” says Cray. “The website is setup similar to an online travel site such as Travelocity or Expedia where you will input your criteria and easily see the various options available.”
The Marketplace website will also include financial screening information to allocate any available subsidies or tax credits available to individuals purchasing plans. In addition to online resources, each state will have designated ACA Navigator sites where individuals can meet face to face with staff that have been federally trained to guide those individuals making policy purchases in the Marketplace. Individuals without an insurance policy will be required to pay a $95 or 1% of their adjusted gross income, whichever is greater, penalty fee to the Federal government.
Additional coverage is also available through expanded Medicaid. However, the Supreme Court ruled in July 2012 that individual states could opt out of the Medicaid expansion component of the ACA. While Florida Governor Rick Scott initially opposed the expansion, he later supported the Medicaid expansion but the measure did not pass through the Florida legislature this past session. The issue can, however, be brought back to a vote in future sessions, therefore allowing another outlet for coverage for qualifying individuals and families.
Getting LGBT-specific
For LGBT families, the Department of Health and Human services has committed to provide the greatest amount of coverage available to LGBT families, particularly in states where same-sex marriage is not recognized. With the Supreme Court rulings ruling DOMA unconstitutional in the summer of 2013, final regulations and best practices for insurance carriers are still being finalized. The Healthcare.gov Marketplace site will include a search option for “domestic partner” polices for same-sex couples to see all available options to them and their family in states where same-sex marriage is not recognized but domestic partnerships are.
Another significant change with the ACA is the ability for young adults to stay fully covered on their parent or guardian’s policy up to the age of 26. This feature will likely prove beneficial to young Americans graduating high school or college that are seeking work in a still difficult economy. For youth within the LGBT community that find themselves thrown out of their homes based on their sexual orientation or gender identity, they will likely be eligible for either Medicaid or qualify for a significant subsidy based on their “homeless” status, therefore increasing their access to often critical healthcare needs and prevention measures.
Taking responsibility
The ACA has dozens upon dozens of components and it is the responsibility of all individuals, families and business owners to educate themselves on the ACA and how it can best be leveraged to their healthy advantage.
“In Florida, opposition to the ACA is very politically motivated and lots of false information has been put out to create confusion,” explains Cray. “You need to find out for yourself what benefits and changes you can expect.”
Pinero believes the implementation of the ACA is a step in the right direction.
“I think the ACA is the first honest attempt to fix a system that is not working properly, so I expect and hope for new amendments and improvements as it gets implemented,” Pinero says. “Regarding what specific benefits will be covered that will affect the LGBT community, I think is still unclear.”
Through all the negative press and opposition Cray believes that the highlighted benefits of the ACA to the LGBT community will live up to the optimistic expectations.
“I think the ACA is one of the best kept secrets in LGBT equality in the United States,” Cray says.
