1. Reaching And assisting LGBT Communities
Kellan Baker, MPH, MA
Out2Enroll Steering Committee
July 8, 2015

2. Federal Agencies Project
Our mission: To connect LGBT people with their new coverage options under the ACA.
“Be out. Be healthy. Get covered.”
Federal Agencies Project

3. Session Goals
Define terms, identities, and concepts associated with LGBT communities.
Describe systematic health care access barriers that LGBT populations have historically faced, and how the Affordable Care Act can help address them.
Identify best practices and practical tips for addressing LGBT-specific enrollment questions.
Develop skills for enrolling LGBT individuals and families effectively.

4. What is LGBTQ? LGBT: Lesbian, Gay, Bisexual, Transgender
Queer: A reclaimed word some LGBT people use to describe their identity as lesbian, gay, bisexual, and/or transgender.
Sexual orientation: Not just about sexuality or who you are attracted to—also about who you love and who you create a family with.
Heterosexual or straight
Gay or lesbian
Bisexual

5. Transgender Terminology
Gender identity: Each person’s deeply felt, internal knowledge of their own gender.
Transgender: A person whose gender identity is different from that typically associated with their assigned sex at birth.
Trans man: A person who was assigned the female sex at birth but identifies and lives as a man.
Trans woman: A person who was assigned the male sex at birth but identifies and lives as a woman.

6. Which of the following is not a term describing sexual orientation?
Straight
Transgender
Heterosexual
Lesbian

7. How many people in the United States identify as LGBT?
700,000
1.3 million
9 million
35 million

8. Where Do LGBT People Live?
Source:

10. What comes to mind when you think about LGBT health?

11. Health Disparities Tobacco and other substance use
Mental health concerns, such as depression and suicide attempts
Certain cancers, such as breast cancer
Experiences of bullying and violence
HIV/AIDS
Source: The Health of Lesbian, Gay, Bisexual and Transgender People (Institute of Medicine, 2011), Healthy People 2020

12. LGBT Health Disparities
Homelessness
Lack of legal recognition
Poverty
Anti-LGBT bias and discrimination
Racism and other structural discrimination
Lack of insurance coverage
Lack of LGBT cultural competence
Source: The Health of Lesbian, Gay, Bisexual and Transgender People (Institute of Medicine, 2011), Healthy People 2020

13. Discrimination
Source: Pew Research Center, June 2013

14. Poverty
Source: Center for American Progress

15. Are LGBT people more likely to be uninsured than non-LGBT people?
Yes No

16. Uninsurance Among LGBT People
Source: Gallup

17. Uninsurance Among Low- and Middle-Income LGBT Adults
Source: Center for American Progress

18. Especially: Same-Sex Couples
Same-sex couples often have difficulty accessing coverage for themselves and their children.
Reasons include:
Lack of legal relationship recognition
Lack of benefits such as employer-sponsored insurance for domestic partners or same-sex spouses
Other employment discrimination
Lack of second-parent adoption rights

19. Updated Oct 17, 2014
Source: Freedom to Marry

20. Especially: Transgender People
Transgender people are frequently denied insurance coverage and health care just because of who they are.
Transgender exclusions remain in many plans.
Types of care affected by exclusions:
Preventive screenings (Pap tests, mammograms)
Mental health counseling
Hormone therapy
Gender confirmation surgeries
Any other kind of care a trans person might need

21. LGBT people want to get covered…
…But they need your help.
90% say health insurance is very important
50% have never shopped for coverage before
80% want LGBT-specific help

22. How can you reach LGBT consumers?

23. Partner with LGBT organizations and use relevant images, language, and content.
LGBT state equality organizations, transgender groups, LGBT community centers, prominent LGBT people

24. Key Messages for LGBT People
LGBT Nondiscrimination
Financial Assistance
Access to Family Coverage
Better Quality Coverage
Source: Center for American Progress

25. LGBT Nondiscrimination
“I understand that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability.”

26. Financial Assistance
If a same-sex couple is legally married in any state and file federal taxes jointly, they can apply jointly for advance premium tax credits, regardless of where they live.
Couples who do not file jointly, including those in a domestic partnership or civil union, need to apply for tax credits individually.
A child’s eligibility for financial assistance is tied to the parent that claims the child on their federal taxes.
Mention number of states with marriage equality

27. Access to Family Coverage
Insurers that offer family or spousal coverage to different- sex spouses must also cover legally married same-sex spouses, regardless of what state they live in.
Florida’s Medicaid program must now consider legally same-sex married couples a family when determining eligibility.

28. Better Quality Coverage
Important new protections for LGBT people with HIV, cancer, or other health conditions:
Plans can no longer deny coverage because of pre-existing conditions.
Plans cannot set annual or lifetime limits on coverage.
Essential health benefits help address LGBT disparities:
Preventive screenings
Mental health and substance use treatment
Prescription drug coverage
Reproductive health care

29. Now that you’ve reached out… What’s next?

30. Create a Welcoming Environment
Display nondiscrimination policies.
Include a general nondiscrimination statement during the opening conversation.
Post “safe space” or rainbow stickers and posters.
Have LGBT reading materials available in waiting areas.
Provide unisex bathrooms.

31. Provide the Right Help Don’t assume anything about people, such as
Gender and gender identity
Appropriate name and gender pronoun
Sexual orientation
Relationship status and family configuration
HIV/AIDS status
When in doubt, politely ask rather than guessing.
“How would you like me to refer to you?” “What pronoun is appropriate?” “How would you like to be addressed?”

32. Be Aware of Language
In addition to he/him/sir and she/her/ma’am, some transgender people may use pronouns such as they/them.
Write down and consistently use the appropriate name and gender pronoun, especially if it’s different from the person’s legal record.
Use gender-neutral language for families, such as “partner,” “spouse,” and “parent.”
“Some of that language stuff is really important, you know? I’d either shut down or I’d get angry. I’d be like, you called me ma’am; are you kidding me?”
– Transgender man

33. Build Trust with LGBT Clients
Give applicants the option to point or write down answers themselves.
Keep the focus on services rather than indulging in questions out of curiosity.
Never disclose a person’s LGBT status to anyone who does not need the information to provide services.
Simply apologize and move on in case of a mistake.

34. Application Assistance
Name and gender – on the form (though not in conversation) rely on what’s on the majority of the applicant’s ID documents
Relationship status – legal relationship recognition?
Household configuration – filing joint federal income taxes?
Plan exclusions – transgender exclusions?
Plan formularies – HIV and other medications?
Provider networks – providers listed on or known as a Ryan White Provider?

35. Case Studies

36. Case Study #1: Maria
Maria contacts you to learn more about enrolling in health insurance coverage. In addition to getting insurance for herself, Maria would also like to get coverage for her wife Jenny and their daughter Sarah.

37. What is the most important determinant of whether Maria and Jenny can get family coverage?
Whether they have children together
Where they were married
How they file federal taxes
What state they live in

38. Case Study #2: Jimmy
Jimmy contacts you to learn more about enrolling in health insurance coverage. He says that he needs a plan that includes providers who have expertise in the treatment of HIV.

39. What are some strategies to help Jimmy find the right plan?

40. Case Study #3: Sam
Sam contacts you by phone to learn more about enrolling in health insurance coverage. When you address Sam as “sir,” Sam corrects you by saying, “Actually, it’s ma’am.”

41. What should you not do next?
Ask what gender Sam’s ID says and just use that
Make a note that Sam identifies as female
Consistently refer to Sam as “she” in the future
Apologize and move on

42. Some LGBT Resources Out2Enroll: www.Out2Enroll.org
Key Lessons for LGBT Outreach and Enrollment Under the Affordable Care Act (Out2Enroll, 2014): content/uploads/2014/07/O2E_KeyLessons_FINAL.pdf
Moving the Needle: The Impact of the Affordable Care Act on LGBT Communities (Center for American Progress, 2014): 7/101575/moving-the-needle/
Where to Start, What to Ask: A Guide for LGBT People Choosing Healthcare Plans (Strong Families Coalition, 2014):

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44. Kellan Baker kellan@out2enroll.org Katie Keith katie@out2enroll.org
Thank you!
Kellan Baker Katie Keith