Research finds health insurance coverage, access to care continued to decline for sexual minorities during COVID

Uninsurance rates among sexual minorities have increased steadily from their low in 2016 in the United States, affecting a population that has historically had fewer opportunities to access comprehensive health services, compared to heterosexual individuals.

These inequities in health insurance coverage and access to care widened even further during the COVID-19 pandemic, according to a new study led by a Boston University School of Public Health (BUSPH) researcher.

Published in the American Journal of Public Health, the study found that sexual minority women were significantly more likely to be uninsured than heterosexual women and sexual minority men faced greater challenges affording necessary care with health insurance than heterosexual men.

The new study builds upon previous research about these disparities but assesses a much larger study population than past studies—nearly 160,000 U.S. adults.

These findings suggest that insurance status is an important driver of access to care for sexual minority populations, and these populations may disproportionately lose health insurance coverage as state-level eligibility rules continue to change across the country following the expiration of Medicaid continuous enrollment protections earlier this year. Medicaid covers higher rates of sexual minority adults than heterosexual adults.

"This steady rise in uninsurance rates beginning in 2017 likely reflects efforts to undermine the Affordable Care Act during President Donald Trump's administration," says study lead and corresponding author Dr. Kevin Nguyen, assistant professor of health law, policy & management. "Our study suggests that sexual minority adults may have been disproportionately impacted by employment loss and health insurance loss during the pandemic."

For the study, Dr. Nguyen and colleagues from BUSPH, Columbia University School of Social Work, and Vanderbilt University utilized data from the Behavioral Risk Factor Surveillance System data to examine differences in health insurance coverage type and access to care by sex and sexual orientation among 158,722 adults ages 18-64, from January 2021 to February 2022.

Overall, about 1 in 8 nonelderly sexual minority adults in 34 states were uninsured in 2021, compared to 1 in 10 heterosexual adults. Sexual minority men and women were much more likely not to have employer-sponsored health insurance compared to heterosexual adults and were more likely to have Medicaid insurance than heterosexual men and women.

Sexual minority women—particularly those who were uninsured—were less likely to have a personal doctor or a checkup in the last two years. While sexual minority men were more likely to report having health insurance and a doctor, they had greater difficulty paying for this care than their heterosexual peers.

The researchers emphasize that public policies likely play a critical role in reducing health inequities. They found that for both men and women, living in states with the most inclusive LGBTQ+ policies narrowed the disparities in inability to afford necessary medical care compared to states with negative LGBTQ+ policies.

Expanding Medicaid in the ten states that have not done so could also reduce inequities in uninsurance for low-income sexual minority adults, the team says. Broader policy changes that support well-being can also help close this gap in access to care.

"Because inequities in health insurance coverage and access to care are, in part, a reflection of discrimination and structural barriers, social policies that codify equality by sexual orientation and/or gender identity—such as passage of the federal Equality Act—could potentially have positive impacts on health, financial security, and access to care," Dr. Nguyen says.