LGBT Medicaid Beneficiaries Have Higher Rates of Unmet Care Needs

Overall, lesbian, gay, bisexual, and transgender (LGBT) Medicaid beneficiaries experienced similar care access as heterosexual beneficiaries and privately insured individuals, but LGBT individuals were more likely to have unmet behavioral health needs and negative experiences with providers, according to a MACPAC issue brief.

Researchers conducted two analyses using data from the National Health Interview Survey from 2015 to 2018, the National Survey on Drug Use and Health from 2015 to 2019, and the US Transgender Survey from 2015.

The first analysis focused on lesbian, gay, and bisexual (LGB) Medicaid beneficiaries and their experiences accessing physical and behavioral health services compared to heterosexual beneficiaries. The second analysis looked at transgender and gender-diverse (TGD) Medicaid beneficiaries and compared their care experiences to privately insured and uninsured TGD adults.

Physical healthcare utilization generally did not differ by sexual orientation, the brief found. Around 80 percent of lesbian, gay, and bisexual adults reported having a usual source of care compared to 85.5 percent of heterosexual adults.

However, the type of healthcare services varied slightly among the beneficiaries. For example, bisexual individuals were more likely to have had a healthcare professional visit than heterosexual adults (92.2 percent versus 84.5 percent).

In addition, LGB adults were more likely to have been tested for HIV (71 percent) than heterosexual adults (54.8 percent).

The likelihood of unmet care needs due to healthcare costs was similar for both LGB adults (55.2 percent) and heterosexual adults (56.3 percent). But LGB adults were more likely to report delayed care due to access barriers, according to the brief.

Thirteen percent of LGB adults reported not having transportation to a care appointment compared to 5.7 percent of heterosexual adults. LGB adults were also more likely to have issues getting an appointment soon enough to address their needs than heterosexual beneficiaries (15.4 percent versus 9.2 percent).

The brief identified significant behavioral health differences among LGB beneficiaries and heterosexual beneficiaries. LGB adults reported higher rates of mental illness, substance use disorder, and unmet mental health needs.

Nearly 20 percent of lesbian and gay adults and 27.6 percent of bisexual adults reported having a major depressive episode, while only 10.7 percent of heterosexual adults said the same. Lesbian and gay adults (39.6 percent) and bisexual adults (52.2 percent) were also more likely than heterosexual adults (27 percent) to report any mental illness.

LGB beneficiaries were more likely to receive mental health and alcohol or drug treatment, but they also had higher rates of unmet mental healthcare treatment and substance use treatment needs. This may indicate that the services these individuals accessed were insufficient to meet their needs, researchers suggested.

The second analysis found that 11 percent of transgender and gender-diverse respondents received health insurance coverage from Medicaid.

TGD Medicaid beneficiaries faced challenges that their privately insured counterparts did not, the brief discovered. For example, TGD Medicaid beneficiaries were more likely to have experienced homelessness in general and due to their gender identity.

Privately insured TGD adults (49.7 percent) were more likely to report very good or excellent health compared to Medicaid beneficiaries (34.6 percent). In addition, half of TGD Medicaid beneficiaries reported serious psychological stress, while 36.9 percent of privately insured adults did.

TGD Medicaid beneficiaries had higher rates of overall substance use, suicidal ideation, and attempted suicide than privately insured individuals.

Most TGD individuals with Medicaid coverage and private insurance saw a provider in the past 12 months, but Medicaid beneficiaries were more likely to report traveling over 25 miles to see a routine provider, the brief noted.

Compared to privately insured adults, TGD Medicaid beneficiaries were more likely to not see a provider due to cost (37 percent versus 27.1 percent) and potential mistreatment due to their gender identity (29 percent versus 23.1 percent).

TGD adults with Medicaid coverage also had a higher likelihood of experiencing negative provider interactions, including having to teach their provider about TGD people, facing refusals for gender-affirming care, being asked invasive questions, and experiencing verbal harassment.

More than half of TGD Medicaid beneficiaries (56 percent) were denied coverage for gender-affirming surgeries, 28 percent were denied coverage for hormones, and 33 percent could not find an in-network provider for surgeries.

Medicaid is a critical source of healthcare coverage for LGBTQ individuals, but the issue brief suggests that there is work to be done to ensure this community has equal access to care as their heterosexual and privately insured counterparts.