Access to health care among gay, lesbian, bisexual, and transgender persons in the United States

Access to care, which has been defined as “the timely use of personal health services to achieve the best health outcomes” (1), has multiple dimensions (2). Examples of dimensions of care include not having health insurance, avoiding care because of costs, delaying care, and not having a trusted physician. A U.S. national study showed that about one-third of gay, lesbian, bisexual, and transgender (GLBT) individuals delayed accessing care because of costs (3). In an analysis of data from the 2014–2015 Behavioral Risk Factor Surveillance System (BRFSS), Gonzales and Blewett (4) found that transgender and gender nonconforming adults were less likely to have routine care and more likely to be uninsured than cisgender women. Disparities in access to healthcare services among sexual minority people are more pronounced among those who are bisexual, Black or Latino, or younger, along with those who have lower income and less educational attainment (5).

Lack of health insurance

Health insurance is a major determinant of access to care as individuals with health insurance are more likely to have a health care provider and to receive care in a timely manner (2). GLBT persons are less likely to have adequate health insurance and more likely to have unmet medical needs than heterosexual persons (6,7). In addition, sexual minorities have been reported to have worse access to care (6,8). Employment-based discrimination may prevent some transgender and gender non-conforming populations from obtaining jobs that offer employer-sponsored health insurance (5). Lack of health insurance has been associated with worse clinical outcomes. For example, lack of insurance in cancer survivors has been associated with forgoing care and poorer clinical outcomes (9). Poverty may also place sexual minorities at increased risk of not having access to health insurance. With the introduction of the Affordable Care Act, fewer sexual minorities in the U.S. lack healthcare insurance (10). In an analysis of data from the 2013, 2014, 2017, and 2018 National Health Interview Surveys, Gonzales et al. (10) found that lack of healthcare insurance declined among sexual minority adults between 2013–2014 and 2017–2018. In an analysis of data from the Health Reform Monitoring Survey, Bolibol et al. (11) found that in 2013 GLBT adults were less likely than non-GLBT adults to have healthcare insurance coverage and more likely to report difficulty obtaining necessary medical care. By 2017–2019, healthcare coverage rates for GLBT adults were comparable to those of non-GLBT adults, but significant disparities in access remained (11).

Avoiding or delaying care because of costs

Sexual minorities are less likely to have a check-up and are more likely to report unmet medical needs (6). In an analysis of data from 12 waves of the biannual Consumer Survey of Health Care Access [2012–2018], Fish et al. (12) found that sexual minority adults other than gay men were less likely to utilize healthcare services due to cost (for example, forgoing or delaying care). Transgender and gender non-conforming adults have lower levels of education, employment, and household income compared to their cisgender counterparts, so they may be less likely to afford medical care (5). Bolibol et al. (11) found that in 2017–2019 GLBT adults were just as likely as non-GLBT adults to report having a usual source of healthcare, but that GLBST adults were more likely to report having difficulty paying medical bills and going without necessary medical care because they could not afford it.

Healthcare discrimination

Sexual minorities are 2 to 3 times more likely than heterosexuals to delay healthcare due to past negative healthcare experiences (13), which is consistent with research on provider discrimination and healthcare access (14). A sizeable literature indicates that transgender individuals experience discrimination by healthcare professionals and within healthcare settings (15). Discriminatory experiences include inappropriate care, care refusal, and mistreatment by healthcare providers (15). One report of transgender patients found that 28% delayed care due to past discrimination, 19% were denied care outright, and 50% reported having to teach their healthcare providers about their healthcare (7).

Access to culturally competent healthcare

Sexual minorities in the U.S. experience barriers to accessing culturally appropriate healthcare that considers their sexuality-related needs within an affirming, respectful and safe environment (4). In 2015, about one-third of transgender adults reported a negative experience with health care providers, such as refusal of care, verbal or physical harassment, or having to teach their providers about transgender health care. Interventions for improving culturally competent care for GLBT persons have been proposed (16,17).

Sexual minority cancer survivors have greater delays in cancer diagnosis and treatment than heterosexual survivors, which may be due to decreased rates of health insurance, poorer access to healthcare, and financial barriers (2). Boehmer et al. (2) found that sexual minority women who were cancer survivors had significantly decreased access to care and that those with access deficits had higher odds of poor physical quality of life, compared with heterosexual women. Poor access to care has been linked to adverse outcomes among cancer survivors, including disease recurrence, poorer survival, and diminished quality of life (2).

Lack of preventive care

Several studies reported disparities in preventive care utilization among GLBT individuals in the United States. For example, lower adherence to annual physical and dental examinations (18), lacking recommended preventative health screening (19-21), and differential uptake of vaccination (22) were commonly observed in the sexually minoritized population. Further, intersectionality of multiple social identities (e.g., race & ethnicity, gender, and sexual orientation), may influence receipt of preventive care (23). As such, GLBT individuals, who often are doubly disadvantaged, endure a higher risk of adverse health outcomes due to underutilization of standard preventive services. This added risk may increase the likelihood of otherwise preventable healthcare-related financial burdens, limiting adequate and timely access to needed healthcare in future.

Conclusions

GLBT persons in the U.S. experience deficits in access to healthcare, related to not having health insurance, avoiding or delaying care because of costs, and not having a trusted physician. Sexual minorities are less likely to have a check-up and are more likely to report unmet medical needs. Lack of health insurance, the delay or refusal of care due to high costs, and the absence of a trusted doctor are critical problems that directly affect the health and well-being of the GLBT community in the U.S. Lack of health insurance has been associated with worse clinical outcomes. The introduction of the Affordable Care Act has increased the proportion of sexual minorities who have health insurance, but further policy changes are needed to help ensure that this population has access to healthcare. In healthcare settings, the provision of continuing professional education on providing culturally competent care for GLBT persons is likely to reduce inappropriate care, care refusal, discrimination, and mistreatment by healthcare providers.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Hospital Management and Health Policy. The article has undergone external peer review.

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-116/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-116/coif). S.S.C. serves as the Associate Editor of Journal of Hospital Management and Health Policy from November 2022 to October 2026. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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