Abstract
Background
Millions of Americans have medical debt and/or defer care due to cost. Few studies have examined the association of such health-related financial problems with sexual orientation or gender identity, and whether state-level policies protecting sexual and gender minority (SGM) people affect disparities in such problems.
Objective
To examine the relationships between SGM status, state-level SGM protections, and health-related financial problems.
Design
Cross-sectional analysis.
Participants
Nationally-representative sample of U.S. adults in the 2021 National Financial Capability Study.
Main Measures
Prevalence of medical debt and/or deferred care; adjusted odds ratios (aORs) by SGM status and residence in a state with fewer SGM protections.
Key Results
Of 25,170 survey respondents, 3.7% were gay/bisexual men, 4.3% lesbian/bisexual women, and 0.6% transgender people. Among lesbian/bisexual women, 39.4% had medical debt, the highest proportion of any group. Accounting for sociodemographic and personal-financial factors, women and all lesbian/gay/bisexual persons (vs. straight men) more often experienced medical debt (aOR [95% CI]: straight women 1.28 [1.16, 1.41], gay/bisexual men 1.55 [1.23, 1.94], lesbian/bisexual women 1.80 [1.50, 2.10]) or deferred care (e.g., 1.80 [1.51, 2.16] for lesbian/bisexual women). Transgender people vs. cisgender men were more likely to defer care (aOR = 2.58 [1.54, 4.30]). Living in a state with fewer SGM protections was associated with higher rates of health-related financial problems for most groups, especially cisgender women and lesbian/bisexual women.
Conclusions
Lesbian/gay/bisexual, female, and transgender adults experience more health-related financial problems, especially in states lacking SGM protections, underlining the importance of universal, comprehensive insurance coverage (including for services unique to SGM people), ending bans on gender-affirming care, and closing the male–female pay gap.
Supplementary Information
The online version contains supplementary material available at 10.1007/s11606-024-09258-9.
KEY WORDS: sexual and gender minorities, medical debt, deferred care
Introduction
Medical debt, which affects 23 million Americans,1 discourages the use of needed medical care,2 damages personal credit,3 and worsens food and housing security.4 Deferring medical care due to cost, another health-related financial problem, is associated with worsening health, poor functional capacity, and increased mortality.5–8 Women, non-Hispanic Black adults, and uninsured adults have elevated levels of medical debt.4 However, little information is available on the association of sexual orientation or gender identity with medical indebtedness,9,10 and while some researchers have explored the association of sexual orientation and gender identity with forgoing care, few recent national data on this issue are available.11–18
Sexual and gender minority (SGM) people have long experienced discrimination in medical care,19–21 housing, and jobs. In response, some U.S. states have implemented state-level policies designed to protect SGM people from discrimination, while others have implemented policies that restrict medical care for SGM people or make it less affordable. For example, as of September 2024, 15 states have laws that prohibit health insurance discrimination based on sexual orientation and gender identity, while 2 states have laws that explicitly allow insurers to deny coverage for gender-affirming care, and 24 states have banned gender-affirming care for transgender youth.22 However, no analyses have assessed the association of medical debt or deferred care with such state-level policies.
We analyzed data from a recent, nationally representative survey to assess the association between sexual orientation or gender identity and medical debt or deferred care due to cost. We also evaluated the association between state-level SGM-related policies and these health-related financial problems among adults with various sexual orientations and gender identities.
Methods
Data Source and Analytic Sample
We analyzed data from the 2021 National Financial Capability Study (NFCS), a nationally representative cross-sectional survey performed triennially by the Financial Industry Regulatory Authority (FINRA) Investor Education Foundation. The survey collects information on demographics including SGM status, personal finances, financial access to medical care, and other financial issues.23 We included only adults (age 18 or older) and excluded respondents who were missing data for SGM status (2.1%) or our primary outcomes (medical debt and/or deferred medical care due to cost, 6.3%).
Outcomes: Medical Debt and Deferred Care
Medical indebtedness was assessed based on a question asking about any unpaid bills from a healthcare or medical service provider that were past due (yes or no). Experiencing deferred care due to cost in the past 12 months (hereafter “deferred care”) was defined based on 3 survey questions assessing deferral of: 1. filling a prescription for medicine; 2. medical tests, treatments, or follow-up recommended by a doctor; or 3. doctor or clinic appointments for a medical problem. Respondents with at least one “yes” response were considered to have deferred care. We also created a composite binary variable for experiencing medical debt and/or deferred care (referred to as either).
Gender Identity and Sexual Orientation Definitions
SGM refers to persons who report sexual orientations other than straight, gender identities other than cisgender, or have other minority sexual or gender characteristics. Sexual orientation refers to the gender/sex people are attracted to, relative to their own gender/sex. Lesbians are women attracted to other women, bisexual people are attracted to either men or women, and gay broadly refers to people attracted to the same gender/sex as themselves.
Gender identity refers to how people internally experience their gender as male, female, a blend of both, or neither. Transgender broadly refers to people whose experience of their gender does not align with their sex assigned at birth (including nonbinary gender identities), while cisgender refers to those whose experience of their gender aligns with their sex assigned at birth. Sexual orientation and gender identity are separate components of identity. Thus, a lesbian/gay/bisexual (LGB) person can have any gender identity, and a transgender person can have any sexual orientation.
Participants were categorized as straight, gay/bisexual, or lesbian/bisexual based on self-identification in the survey. Those who self-identified as transgender were categorized as such. The survey did not include an option to self-identify as cisgender. Hence, we classified all non-transgender persons as cisgender, although this may not accurately describe all individuals' identities. Survey questions precluded differentiation between transgender women and transgender men; thus, gender identity analyses inaccurately assume a singular experience by gender among transgender people, but not cisgender people. The < 0.01% of respondents who indicated “something else” in response to the sexual orientation/gender identity questions were excluded from analyses since the survey question was unclear about whether “something else” referred to a gender identity or sexual orientation. See Supplement Methods for the exact survey questions.
Sociodemographic Covariates
Sociodemographic covariates included age (18- < 45, 45- < 65, ≥ 65 years), race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic other), education level (high school or less, some college, college degree, post-graduate), urbanicity (most urban, metropolitan, small town/rural), veteran status, living arrangements (lone adult, living with partner/spouse, living with parents, living with roommates), and state of residence. Veteran status was included given veterans’ access to a different payment model for healthcare through the VA.
Personal-Financial Covariates
Personal-financial covariates included employment (employed, unemployed, disabled, retired), household income (< $15 k, $15 k- < $35 k, $35 k- < $50 k, $50 k- < $75 k, $75 k- < $100 K, ≥ $100 k), number of financially dependent children (none, 1, 2, ≥ 3), having health insurance, owning a home, having an emergency fund (money set aside to cover expenses for 3 months), and difficulty paying monthly bills (not at all difficult, somewhat difficult, very difficult).
SGM Policies
We assessed state-level policies related to SGM people using the Human Rights Campaign’s (HRC) 2021 state equality index (SEI).24 The HRC issues an annual report evaluating each state’s laws and policies in 6 topic areas related to SGM rights and protections (Supplement Table 1), and ranks states into four ordered SEI categories ranging from few to many SGM protections.
Because most states were either category 1 (the fewest protections) or category 4 (the most protections), we collapsed the SEI categories into low SEI (categories 1 and 2; 26 states, 48.4% of sample), or high SEI (categories 3 and 4; 24 states, 51.6% of sample) (Supplement Table 2). We assigned each participant to a SEI category based on their state of residence.
Analysis
Respondents’ characteristics were tabulated by sexual orientation (straight men; gay/bisexual men; straight women; lesbian/bisexual women), and by gender identity (cisgender men; cisgender women; transgender people). Sexual orientation analyses included only cisgender respondents due to the small number of transgender respondents.
We calculated the prevalence of each outcome (medical debt, deferred care, either) for each sexual orientation and gender identity. We then performed unadjusted logistic regressions for each outcome, with either sexual orientation or gender identity as the exposure. Each model was then repeated, first with adjustment for sociodemographic characteristics, and then with adjustment for both sociodemographic and personal-financial characteristics.
We then reran these logistic regression models with an interaction term between sexual orientation (or gender identity) and SEI to assess whether the association between SGM status and having either medical debt or deferred care differed between states with few (low SEI) vs. many protections (high SEI). We report these results as predicted margins.
Analyses were conducted using SAS 9.4 survey procedures with weights provided by FINRA to generate national estimates. We compared proportions using chi-square tests with two-tailed p-values < 0.05 considered statistically significant. The Cambridge Health Alliance Institutional Review Board does not consider analyses of deidentified public use data to be human subjects research.
Results
Of 25,133 survey respondents, 48.3% identified as cisgender men, 49.1% as cisgender women, and 0.6% as transgender people (all estimates weighted). Of 25,007 cisgender respondents, 44.9% identified as straight men, 3.7% as gay/bisexual men, 47.1% as straight women, and 4.3% as lesbian/bisexual women.
Compared to those identifying as straight, LGB respondents were younger and more likely to be Hispanic, unmarried, unemployed, and low-income (Table 1). They were also less likely to have an emergency fund or own their home, and more likely to have difficulty paying monthly bills. Lesbian/bisexual women were less educated and less likely to have health insurance than straight women. Gay/bisexual men were less likely to have financially dependent children than straight men.
Table 1.
Respondent Characteristics by Sexual Orientation or Gender Identity
| Characteristics | Sexual Orientation* | Gender Identity | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Men | Women | |||||||||
| Straight | Gay or Bisexual | p-value | Straight | Lesbian or Bisexual | p-value | Cisgender Men | Cisgender Women | Transgender People | p-value | |
|
N = 10,615 % (SE) |
N = 871 % (SE) |
N = 12,358 % (SE) |
N = 1,163 % (SE) |
N = 11,486 % (SE) |
N = 13,521 % (SE) |
N = 126 % (SE) |
||||
| Age (years) | ||||||||||
| 18 to < 45 | 44.5 (0.58) | 54.3 (2.03) | < 0.001 | 37.5 (0.52) | 84.0 (1.24) | < 0.001 | 45.2 (0.56) | 41.4 (0.50) | 92.7 (2.29) | < 0.001† |
| 45 to < 65 | 35.7 (0.56) | 34.1 (1.91) | 37.8 (0.52) | 13.3 (1.15) | 35.6 (0.54) | 35.6 (0.54) | 7.3 (2.29) | |||
| ≥ 65 | 19.8 (0.45) | 11.6 (1.24) | 24.7 (0.47) | 2.6 (0.54) | 19.2 (0.43) | 19.2 (0.43) | 0 | |||
| Race | ||||||||||
| NH‡ White | 63.5 (0.61) | 62.1 (2.15) | 0.051 | 65.3 (0.55) | 59.7 (1.81) | 0.001 | 63.4 (0.59) | 64.8 (0.53) | 50.0 (5.73) | < 0.001 |
| NH‡ Black | 12.0 (0.38) | 10.4 (1.21) | 11.1 (0.34) | 13.2 (1.15) | 11.9 (0.36) | 11.3 (0.32) | 4.8 (2.2) | |||
| Hispanic | 16.4 (0.57) | 20.8 (2.10) | 14.6 (0.49) | 19.3 (1.74) | 16.7 (0.54) | 15.0 (0.47) | 34.6 (6.3) | |||
| NH‡ Other | 8.1 (0.33) | 6.7 (1.02) | 9.0 (0.32) | 7.8 (0.88) | 8.0 (0.31) | 8.9 (0.30) | 10.5 (3.03) | |||
| Education | ||||||||||
| HS§ or Less | 27.9 (0.54) | 28.9 (1.95) | 0.89 | 30.6 (0.50) | 36.4 (1.68) | < 0.001 | 28.0 (0.52) | 31.1 (0.48) | 31.2 (5.29) | < 0.001 |
| Some College | 25.6 (0.52) | 24.4 (1.75) | 28.9 (0.49) | 34.4 (1.71) | 25.5 (0.50) | 29.4 (0.47) | 38.3 (5.53) | |||
| College Degree | 36.0 (0.55) | 36.6 (1.96) | 31.1 (0.49) | 23.9 (1.43) | 36.1 (0.53) | 30.5 (0.46) | 28.1 (5.33) | |||
| Postgraduate | 10.5 (0.32) | 10.1 (1.10) | 9.4 (0.30) | 5.3 (0.77) | 10.5 (0.31) | 9.1 (0.28) | 2.4 (1.18) | |||
| Urbanicity | ||||||||||
| Most Urban | 73.6 (0.49) | 78.9 (1.62) | 0.008 | 69.7 (0.47) | 72.7 (1.48) | 0.080 | 74.0 (0.47) | 70.0 (0.45) | 78.4 (4.85) | < 0.001 |
| Metropolitan | 18.9 (0.43) | 15.7 (1.47) | 21.4 (0.42) | 20.3 (1.34) | 18.6 (0.41) | 21.3 (0.40) | 19.8 (4.83) | |||
| Small Town/Rural | 7.6 (0.28) | 5.4 (0.83) | 8.8 (0.27) | 7.0 (0.78) | 7.4 (0.26) | 8.7 (0.26) | 1.8 (0.78) | |||
| Marital Status | ||||||||||
| Married | 52.0 (0.58) | 29.0 (1.82) | < 0.001 | 48.4 (0.54) | 27.2 (1.58) | < 0.001 | 50.3 (0.56) | 46.6 (0.51) | 14.1 (4.03) | < 0.001 |
| Never Married | 35.4 (0.57) | 62.8 (1.95) | 27.6 (0.48) | 58.7 (1.71) | 37.4 (0.55) | 30.2 (0.47) | 79.8 (4.73) | |||
| Previously Married | 12.6 (0.38) | 8.2 (1.03) | 24.1 (0.46) | 14.1 (1.12) | 12.3 (0.36) | 23.2 (0.43) | 6.1 (2.98) | |||
| Veteran | 22.0 (0.48) | 14.6 (1.34) | < 0.001 | 4.3 (0.22) | 5.4 (0.79) | 0.125 | 21.5 (0.46) | 4.4 (0.21) | 12.2 (4.21) | < 0.001 |
| Employment Status | ||||||||||
| Employed | 62.5 (0.57) | 59.9 (2.03) | < 0.001 | 45.2 (0.53) | 54.8 (1.75) | < 0.001 | 62.3 (0.55) | 46.0 (0.51) | 54.9 (5.69) | < 0.001 |
| Unemployed | 11.2 (0.40) | 18.2 (1.74) | 22.3 (0.45) | 35.0 (1.70) | 11.8 (0.39) | 23.3 (0.44) | 37.3 (5.53) | |||
| Disabled | 4.6 (0.24) | 6.3 (0.94) | 6.6 (0.28) | 6.2 (0.80) | 4.7 (0.23) | 6.5 (0.26) | 6.8 (2.81) | |||
| Retired | 21.7 (0.47) | 15.4 (1.43) | 25.9 (0.47) | 3.9 (0.66) | 21.2 (0.45) | 24.1 (0.44) | 1.0 (0.75) | |||
| Annual Household Income | ||||||||||
| < $15 k | 10.1 (0.37) | 15.0 (1.52) | < 0.001 | 12.7 (0.36) | 22.8 (1.48) | < 0.001 | 10.4 (0.36) | 13.5 (0.35) | 21.1 (4.06) | < 0.001 |
| $15 k—< $35 k | 17.3 (0.45) | 23.2 (1.80) | 25.7 (0.48) | 29.3 (1.60) | 17.8 (0.44) | 26.0 (0.46) | 37.1 (5.81) | |||
| $35 k—< $50 k | 13.0 (0.39) | 16.0 (1.55) | 15.0 (0.38) | 17.5 (1.27) | 13.3 (0.38) | 15.2 (0.36) | 16.9 (4.36) | |||
| $50 k—< $75 k | 19.3 (0.47) | 16.0 (1.46) | 18.6 (0.42) | 14.7 (1.23) | 19.0 (0.44) | 18.3 (0.40) | 8.3 (3.09) | |||
| $75 k—< $100 k | 14.7 (0.40) | 10.0 (1.21) | 12.1 (0.34) | 6.3 (0.85) | 14.3 (0.38) | 11.7 (0.32) | 7.1 (3.12) | |||
| > $100 k | 25.6 (0.50) | 19.7 (1.53) | 15.8 (0.38) | 9.4 (1.09) | 25.1 (0.47) | 15.3 (0.36) | 9.5 (2.79) | |||
| Living arrangements | ||||||||||
| Lone adult | 25.3 (0.51) | 41.6 (2.01) | < 0.001 | 26.3 (0.48) | 21.9 (1.41) | < 0.001 | 26.5 (0.50) | 25.9 (0.45) | 16.1 (3.77) | < 0.001 |
| Living with partner/spouse | 56.6 (0.58) | 34.7 (1.96) | 55.5 (0.53) | 45.4 (1.74) | 55.0 (0.56) | 54.6 (0.51) | 29.0 (5.45) | |||
| Living with parents | 9.1 (0.37) | 11.9 (1.42) | 6.6 (0.28) | 18.6 (1.46) | 9.3 (0.35) | 7.6 (0.29) | 30.0 (5.23) | |||
| Living with roommates | 9.1 (0.37) | 11.8 (1.32) | 11.6 (0.35) | 14.1 (1.21) | 9.2 (0.33) | 11.8 (0.34) | 24.8 (4.92) | |||
| Financially Dependent Children | ||||||||||
| None | 65.5 (0.55) | 78.1 (1.70) | < 0.001 | 66.1 (0.51) | 62.2 (1.70) | 0.110 | 66.4 (0.53) | 65.8 (0.49) | 80.6 (4.87) | 0.018 |
| 1 | 14.7 (0.41) | 10.6 (1.33) | 15.1 (0.38) | 16.2 (1.30) | 14.4 (0.39) | 15.2 (0.37) | 8.1 (3.69) | |||
| 2 | 12.6 (0.38) | 7.3 (1.06) | 11.3 (0.34) | 12.2 (1.14) | 12.2 (0.36) | 11.4 (0.32) | 3.3 (2.04) | |||
| 3 or more | 7.3 (0.31) | 4.1 (0.68) | 7.5 (0.28) | 9.3 (1.03) | 7.0 (0.29) | 7.7 (0.27) | 8.0 (3.20) | |||
| Health Insurance (any) | 88.7 (0.40) | 86.6 (1.54) | 0.167 | 91.4 (0.30) | 85.3 (1.21) | < 0.001 | 88.5 (0.39) | 90.9 (0.29) | 84.5 (4.27) | < 0.001 |
| Emergency Fund|| | 62.1 (0.58) | 55.2 (2.08) | 0.001 | 52.9 (0.55) | 40.1 (1.78) | < 0.001 | 61.6 (0.56) | 51.8 (0.52) | 38.3 (5.89) | < 0.001 |
| Owns Home | 63.6 (0.57) | 49.7 (2.07) | < 0.001 | 59.9 (0.53) | 33.0 (1.66) | < 0.001 | 62.6 (0.55) | 57.6 (0.51) | 23.4 (4.87) | < 0.001 |
| Difficulty Paying Monthly Bills? | ||||||||||
| Not at all Difficult | 61.4 (0.58) | 50.1 (2.08) | < 0.001 | 54.0 (0.54) | 35.0 (1.72) | < 0.001 | 60.5 (0.56) | 52.4 (0.52) | 39.1 (6.06) | < 0.001 |
| Somewhat Difficulty | 30.4 (0.55) | 33.3 (1.98) | 35.1 (0.52) | 47.4 (1.76) | 30.6 (0.53) | 36.1 (0.50) | 45.8 (5.81) | |||
| Very Difficult | 8.2 (0.32) | 16.6 (1.67) | 11.0 (0.34) | 17.6 (1.29) | 8.9 (0.33) | 11.5 (0.33) | 15.1 (3.70) | |||
| Resides in Low State Equality Index State¶ | 49.4 (0.58) | 43.9 (2.02) | 0.009 | 47.8 (0.53) | 47.1 (1.74) | 0.67 | 49.0 (0.56) | 47.8 (0.51) | 45.4 (5.71) | 0.27 |
* Cisgender (i.e. non-transgender) respondents only
† p value approximate due to a 0 count in one cell
‡ NH = non-Hispanic
§ HS = high school
|| Having an emergency fund refers to respondents saying they have money set aside that would cover expenses for 3 months, in case of sickness, job loss, economic downturn, or other emergencies
¶ States with low state equality index have fewer protections for gender and sexual minorities than states with high state equality index. See text in methods for details
Compared to cisgender adults, transgender adults were younger and more likely to be Hispanic or non-Hispanic other race, unemployed, unmarried, low-income, and have difficulty paying monthly bills.
Medical Debt and Deferred Care
In unadjusted analyses, LGB adults had a higher prevalence of medical debt and/or deferred care than straight adults (e.g. 39.4% for lesbian/bisexual women vs. 19.7% for straight men). Women generally had a higher prevalence of medical debt and/or deferred care compared to men. Lesbian/bisexual women had the highest prevalence of either medical debt and/or deferred care among sexual orientation groups (60.7% vs. 31.8% of straight men, 37.2% of straight women, and 43.8% of gay/bisexual men) (Table 2).
Table 2.
Prevalence of Medical Debt or Deferred Care Due to Cost, by Sexual Orientation and Gender Identity*
| Outcome | Gender Identity | Straight (N = 23,007) |
Lesbian, Gay, or Bisexual (N = 2,163) |
p-value |
|---|---|---|---|---|
| % (SE) | % (SE) | |||
| Medical Debt | Men | 19.7 (0.46) | 28.1 (1.91) | < 0.001 |
| Women | 23.7 (0.45) | 39.4 (1.70) | < 0.001 | |
| p-value | < 0.001 | < 0.001 | N/A | |
| Deferred Care | Men | 24.1 (0.50) | 33.5 (1.95) | < 0.001 |
| Women | 27.0 (0.47) | 46.9 (1.74) | < 0.001 | |
| p-value | < 0.001 | < 0.001 | N/A | |
| Composite Outcome (Medical Debt and/or, Deferred Care) | Men | 31.8 (0.54) | 43.8 (2.05) | < 0.001 |
| Women | 37.2 (0.52) | 60.7 (1.74) | < 0.001 | |
| p-value | < 0.001 | < 0.001 | N/A |
* Includes cisgender (i.e.non-transgender) individuals only
Compared to cisgender men, a higher proportion of cisgender women reported medical debt, deferred care, or either, while transgender people had significantly higher rates of both health-related financial outcomes than cisgendered persons (Table 3). For example, 58.9% of transgender people had medical debt and/or deferred care, vs. 39.1% of cisgender women and 32.7% of cisgender men.
Table 3.
Prevalence of Medical Debt and Deferred Care Due to Cost by Gender Identity
| Outcome | Cisgender Men (N = 11,486) |
Cisgender Women (N = 13,521) |
Transgender People (N = 126) |
p-value |
|---|---|---|---|---|
| % (SE) | % (SE) | % (SE) | ||
| Medical Debt | 20.3 (0.45) | 25.0 (0.44) | 34.3 (5.70) | < 0.001 |
| Deferred Care | 24.8 (0.49) | 28.7 (0.46) | 51.2 (5.76) | < 0.001 |
| Composite (Medical Debt and/or Deferred Care) | 32.7 (0.53) | 39.1 (0.50) | 58.9 (5.70) | < 0.001 |
The unadjusted odds of medical indebtedness for gay/bisexual men, lesbian/bisexual women, and straight women were higher than for straight men (Table 4); differences remained significant after adjusting for sociodemographic covariates and for personal-financial factors (aOR [95% CI]: 1.55 [1.23, 1.94] for gay/bisexual men; 1.28 [1.16, 1.41] for straight women; 1.80 [1.50, 2.17] for lesbian/bisexual women). The patterns were similar for deferred care (e.g. aOR [95% CI]: 1.80 [1.51, 2.16] for lesbian/bisexual women) and the composite outcome (e.g. aOR [95% CI]: 2.13 (1.77, 2.57) for lesbian/bisexual women).
Table 4.
Unadjusted and Adjusted Odds of Reported Medical Debt, Deferred Care, or Either by Sexual Orientation or Gender Identity Groups
| Outcome | Analysis | Independent Variable | Unadjusted Models | Models Adjusted for Sociodemographic* Factors | Models Adjusted for Sociodemographic* and Financial† Factors |
|---|---|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | |||
| Medical Debt | Sexual Orientation models‡ | Straight Men | Ref | Ref | Ref |
| Gay/bisexual Men | 1.60 (1.31, 1.94) | 1.65 (1.34, 2.02) | 1.55 (1.23, 1.94) | ||
| Straight Women | 1.27 (1.17, 1.34) | 1.52 (1.40, 1.65) | 1.28 (1.16, 1.41) | ||
| Lesbian/bisexual Women | 2.66 (2.29, 3.10) | 2.23 (1.89, 2.62) | 1.80 (1.50, 2.17) | ||
| Gender Identity models | Cisgender Men | Ref | Ref | Ref | |
| Cisgender Women | 1.31 (1.22, 1.41) | 1.52 (1.40, 1.65) | 1.28 (1.17, 1.40) | ||
| Transgender People | 2.06 (1.25, 3.39) | 1.60 (0.96, 2.68) | 1.55 (0.87, 2.79) | ||
| Deferred Care | Sexual Orientation models‡ | Straight Men | Ref | Ref | Ref |
| Gay/bisexual Men | 1.60 (1.33, 1.90) | 1.47 (1.22, 1.78) | 1.33 (1.07, 1.64) | ||
| Straight Women | 1.17 (1.09, 1.26) | 1.42 (1.31, 1.54) | 1.26 (1.15, 1.38) | ||
| Lesbian/bisexual Women | 2.78 (2.40, 3.22) | 2.12 (1.82, 2.48) | 1.80 (1.51, 2.16) | ||
| Gender Identity models | Cisgender Men | Ref | Ref | Ref | |
| Cisgender Women | 1.22 (1.14, 1.31) | 1.43 (1.33, 1.55) | 1.27 (1.17, 1.39) | ||
| Transgender People | 3.18 (2.02, 5.01) | 2.18 (1.34, 3.53) | 2.58 (1.54, 4.30) | ||
| Composite (Medical Debt and/or, Deferred Care) | Sexual Orientation models‡ | Straight Men | Ref | Ref | Ref |
| Gay/bisexual Men | 1.67 (1.41, 1.98) | 1.62 (1.35, 1.94) | 1.47 (1.20, 1.80) | ||
| Straight Women | 1.27 (1.19, 1.36) | 1.51 (1.40, 1.63) | 1.31 (1.20, 1.42) | ||
| Lesbian/bisexual Women | 3.31 (2.85, 3.85) | 2.57 (2.19, 3.01) | 2.13 (1.77, 2.57) | ||
| Gender Identity models | Cisgender Men | Ref | Ref | Ref | |
| Cisgender Women | 1.32 (1.24, 1.41) | 1.53 (1.42, 1.64) | 1.33 (1.22, 1.44) | ||
| Transgender People | 2.95 (1.85, 4.69) | 2.05 (1.25, 3.36) | 2.10 (1.17, 3.76) |
* Sociodemographic covariates include age, race and ethnicity, education level, urbanicity, veteran status, living arrangements, and state of residence
† Financial covariates include employment status, income, financially dependent kids, health insurance, owns home, emergency fund, and level of difficulty paying monthly bills
‡ Sexual orientation models performed only on cisgender individuals
The unadjusted odds of medical debt were higher for cisgender women and transgender people relative to cisgender men. Differences remained significant for cisgender women but not transgender people in adjusted models (Table 4). Patterns were similar in models evaluating deferred care or the composite outcome, except that the aORs for transgender people remained significant for both deferred care (aOR [95% CI]): 2.58 [1.54, 4.30]) and for the composite outcome (aOR [95% CI]: 2.10 [1.17, 3.76]).
State-Level Policy Analysis
In states with fewer state-level protections (low SEI), the adjusted prevalence of the composite outcome (either medical debt or deferred care) was higher for straight men (53.3% vs. 48.3%, p-value 0.001), straight women (61.8% vs. 53.0%, p-value < 0.001), and lesbian/bisexual women (76.9% vs. 60.9%, p-value < 0.00), but not gay/bisexual men (Table 5; Fig. 1, panel A). Similarly, the adjusted prevalence of the composite outcome was higher in states with low SEI for cisgender men (53.6% vs. 48.9%, p-value 0.001) and cisgender women (63.0% vs. 53.5%, p-value < 0.001), while for transgender people, the numerically large difference (75.6% vs. 62.5%) was non-significant (Table 5; Fig. 1, panel B). Statistically significant interaction terms between sexual orientation (or gender identity) and SEI indicated that relative to non-SGM men, living in states with fewer state-level SGM protections was more strongly associated with the composite outcome among straight women (p-value 0.045), lesbian/gay women (p-value 0.002), and cisgender women (p-value 0.009).
Table 5.
Unadjusted and Adjusted Prevalence of Composite Outcome (Medical Debt and/or Deferred Care Due to Cost) by Sexual Orientation and Gender Identity by State Equality Index (High vs. Low) with Interaction Term
| Sexual Orientation or Gender Identity Groups | Unadjusted % (SE) of Composite Either Medical Debt and/or Deferred Care | Adjusted* %† (95% CI) of Composite Either Medical Debt and/or Deferred Care | High vs. Low SEI‡ (% Point Difference) | p-value for pairwise test (High vs. Low SEI‡) | Interaction of SEI‡ with Sexual Orientation or Gender Identity (Additional Percentage Point Difference) | p-value for interaction term | |
|---|---|---|---|---|---|---|---|
| Sexual Orientation Groups | Straight Men High | 28.6 (0.77) | 48.3 (44.7, 52.0) | Ref | N/A | N/A | N/A |
| Straight Men Low | 35.0 (0.76) | 53.3 (49.8, 56.8) | 5.0 | 0.001 | Ref | N/A | |
| Gay/ Bisexual Men High | 41.5 (2.84) | 57.9 (50.7, 64.8) | Ref | N/A | N/A | N/A | |
| Gay/ Bisexual Men Low | 46.6 (2.97) | 61.7 (54.5, 68.4) | 3.8 | 0.42 | −1.2 | 0.84 | |
| Straight Women High | 32.1 (0.72) | 53.0 (49.3, 56.6) | Ref | N/A | N/A | N/A | |
| Straight Women Low | 42.7 (0.74) | 61.8 (58.3, 65.1) | 8.8 | < 0.001 | 3.8 | 0.045 | |
| Lesbian/ Bisexual Women High | 51.4 (2.51) | 60.9 (54.4, 67.0) | Ref | N/A | N/A | N/A | |
| Lesbian/ Bisexual Women Low | 71.1 (2.22) | 76.9 (71.5, 81.6) | 16.0 | < 0.001 | 11.0 | 0.002 | |
| Gender Identity Groups | Cisgender Men High | 29.7 (0.75) | 48.9 (45.3, 52.5) | Ref | N/A | N/A | N/A |
| Cisgender Men Low | 35.8 (0.74) | 53.6 (50.2, 57.1) | 4.7 | 0.001 | Ref | N/A | |
| Cisgender Women High | 33.7 (0.69) | 53.5 (49.8, 57.1) | Ref | N/A | N/A | N/A | |
| Cisgender Women Low | 45.1 (0.71) | 63.0 (59.6, 66.2) | 9.5 | < 0.001 | 4.8 | 0.009 | |
| Trans-gender People High | 51.4 (7.70) | 62.5 (42.6, 79.0) | Ref | N/A | N/A | N/A | |
| Trans-gender People Low | 67.9 (8.59) | 75.6 (58.7, 87.2) | 13.1 | 0.27 | 8.4 | 0.45 | |
* Models adjusted for sociodemographic covariates including age, race and ethnicity, education level, urbanicity, veteran status, living arrangements, and personal-financial covariates including employment status, income, financially dependent kids, health insurance, owns home, emergency fund, and level of difficulty paying monthly bills
† Adjusted percentages are least square means from logistic regression models (eModels 1–2) with interaction terms between SEI and sexual orientation or gender identity
‡ State Equality Index
Figure 1.
Adjusted prevalence of medical debt or deferred care due to cost by State Equality Index (high [blue bars] vs. low [red bars]) and by sexual orientation (panel A) and gender identity (panel B). Adjusted by age, race and ethnicity, education level, urbanicity, veteran status, living arrangements, employment status, income, financially dependent kids, health insurance, owns home, emergency fund, and level of difficulty paying monthly bills. P-values represent pairwise testing between high state equality index and low state equality index within each sexual orientation or gender identity.
Similar patterns were observed for the individual outcomes of medical debt and deferred care (Supplement Tables 3 and 4). Persons of all sexual orientations and gender identities (except for gay/bisexual men) had higher prevalences of medical debt and deferred care if they resided in a low (vs. high) SEI state, although differences in prevalence for transgender people, while numerically large, were not statistically significant. SEI had a stronger association for some groups, as demonstrated by a significant interaction term for deferred care among lesbian/bisexual women (Supplement Table 4) and for both medical debt and deferred care among cisgender women (Supplement Tables 3–4). The association of fewer SGM protections on health-related financial outcomes for transgender people was numerically stronger than for cisgender men, but the interaction terms were nonsignificant (Supplement Tables 3–4).
Discussion
Compared to other adults, those who identify as a SGM (and especially as a lesbian/bisexual woman or a transgender person) experience more medical indebtedness and/or deferred care due to cost. Deficient state-level policies protecting SGM people likely contribute to these disparities.
SGM people often have less ability to pay for healthcare. When compared to non-SGM adults, SGM adults (and particularly lesbian/bisexual women and transgender people) have lower household incomes and less wealth (as indicated in our data by lower rates of home ownership and lesser availability of emergency funds). They may also be more likely to reside in urban areas with higher costs of living and healthcare.25,26 Although lesbian/bisexual (vs. straight) women are more likely to be employed, their household incomes are lower. Additionally, unlike other recent studies that have found similar insurance rates among the SGM and non-SGM populations (after improvements in recent years),17,27 we found lower rates of health insurance for lesbian/bisexual women (vs. straight women) and transgender people (vs. cisgender people).
Adjustment for financial factors only modestly attenuated the observed associations between SGM status and health-related financial problems. This suggests that other unmeasured factors (e.g. specific health needs related to chronic illness, substance use or mental health conditions, or inadequate insurance) might play a role. For example, compared to straight women, lesbian/bisexual women have higher rates of obesity, cardiac disease, and diabetes.28–31 They (along with transgender people) also experience elevated rates of sexual assault, which often leads to high out-of-pocket costs.20,32,33 Other studies have found that SGM adults are more likely to avoid routine care and to lack a usual place of care, which may contribute to worse health status and thus more expensive care in the future.20,25,27,34 Additionally, SGM people often have unique health needs requiring health services for which insurance coverage is often inadequate, including fertility treatments, antiretrovirals, and gender-affirming care.35–40 While information on insurance type was not available in the dataset we analyzed, Nguyen et al. found that sexual minority adults are less likely to have employer sponsored coverage and more likely to be enrolled in Medicaid or in individual or marketplace plans, which are often high deductible plans (HDP).41 Additionally, Tran et al. found that bisexual adults were more likely to be enrolled in HDP, and that having a HDP was associated with deferring care, particularly for sexual minority adults.42 Such differential insurance enrollment patterns might contribute to the disparities we identified, because HDP are known to restrict access due to cost,43 and Medicaid may not be comprehensive nor accepted by all providers.44
Our finding that in states with few SGM protections, almost all groups were more likely to experience medical debt and deferred care, suggests that SGM protections may be associated with other social policies (e.g. Medicaid expansion, higher minimum wages) that improve financial access to care. However, SGM protections appeared to have particularly large benefits for lesbian/bisexual women and transgender persons. Specific policies measured by the SEI that might impact health-related financial problems for SGM people include those addressing: employment discrimination; insurance coverage exclusions for gender-affirming and infertility care; and discrimination more broadly, since discriminatory social environments harm health, increase risky behavior, and worsen access to care.45–48 The lack of a significant association between SEI and health related financial outcomes in gay/bisexual men may reflect a lack of state level variation in some important policies, such as insurance coverage of PrEP which has historically been poor in all states.35,40,49
Our study is the first to demonstrate a higher prevalence of medical debt among individual SGM identities nationally, confirming the findings of two non-peer reviewed reports based on small samples, which excluded transgender persons and/or those with insurance.9,10 Our observations regarding deferred care align with older studies including: two (which excluded unpartnered SGM and transgender people) that found higher odds of deferred care among LGB people;14,16 an analysis (which excluded transgender people) that found more deferred care among white LGB persons and non-white lesbian/bisexual women compared to straight white men;13 and another (which also excluded transgender people) that documented higher odds of deferred care among LGB vs. straight persons of similar gender.{Hsieh, 2017 #220}11 One study of transgender people found elevated rates of deferred care.12 More recent studies evaluating SGM identities as a singular group have reported a prevalence of deferred care similar in magnitude to our findings,15,18 and higher prevalence of deferred care among LGB vs. straight adults.17 Our results provide a more recent, comprehensive picture of health-related financial problems for a fuller spectrum of SGM identities.
Limitations
Our study has several limitations. We had no information on respondents’ health status, medical expenditures, or type of insurance. The SEI, which we used to assess state-level SGM protections, aggregates multiple individual policies, and is thus uninformative regarding specific policies’ effectiveness. Relatively few transgender people were included in the sample we analyzed; additionally, given the oppression of SGM people, respondents may have under-reported SGM status. Survey structure and sample size precluded analyzing transgender women and men separately. Our outcomes were based on self-report and some respondents may be unaware that they are carrying debt. Finally, observational studies such as ours cannot prove causation.
Policy Implications/Recommendations
Several policy changes might reduce medical debt and deferred care for SGM people. First, removing discrimination from health insurance by improving coverage of services unique to SGM people could decrease medical expenditures, e.g. for LGB women and transgender people, dropping insurers’ restrictions on payment for fertility services when infertility has not been demonstrated by inability to conceive through heterosexual intercourse;36 ensuring coverage of PrEP for gay/bisexual men, transgender women who have sex with men, and other qualifying SGM people;40 and for transgender people, removing exclusions for gender-affirming care. Second, recent state-level bans on gender-affirming care are clearly discriminatory and may increase medical debt or deferred care by requiring transgender people to travel for care or pay under-the-table for banned services. Third, antidiscrimination protections for employment and housing might improve ability to pay for care. Fourth, while the relationship of SGM status with wages is complex,50 eliminating the male:female wage gap would aid women regardless of sexual orientation. Finally, increasing antidiscrimination protections in general could improve cultural environments, reducing psychological distress and/or avoidance of routine preventive care, and ultimately reduce illness and costs.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements:
This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) as part of an award totaling $550,341 with 158% percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. This work was presented at the 2024 Society of General Internal Medicine Annual Meeting on May 17th, 2024. All authors have significantly contributed to this work. To the best of our knowledge, none of our authors have any conflicts of interest of any type.
Funding
EL received financial support by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) as part of an award totaling $550,341 with 158% percentage financed with non-governmental sources.
Data Availability
The data that support the findings of this study are publicly available at the following URL: https://www.finrafoundation.org/data-and-downloads.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Rae M, Claxton G, Amin K, Wager E, Ortaliza J, Cox C. The burden of medical debt in the United States. Peterson-KFF Health System Tracker. 2022. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/#Share%20of%20adults%20who%20have%20more%20than%20$250%20in%20medical%20debt,%20by%20demographic,%202019. Accessed 1 July 2023.
- 2.Kalousova L, Burgard SA. Debt and foregone medical care. J Health Soc Behav. 2013;54(2):204-20. [DOI] [PubMed] [Google Scholar]
- 3.Brevoort K, Grodzicki D, Hackmann MB. The credit consequences of unpaid medical bills. J Public Econ. 2020;187:104203. [Google Scholar]
- 4.Himmelstein DU, Dickman SL, McCormick D, Bor DH, Gaffney A, Woolhandler S. Prevalence and risk factors for medical debt and subsequent changes in social determinants of health in the US. JAMA Netw Open. 2022;5(9):e2231898. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Prentice JC, Pizer SD. Delayed access to health care and mortality. Health Serv Res. 2007;42(2):644-62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.McQueenie R, Ellis DA, McConnachie A, Wilson P, Williamson AE. Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study. BMC Med. 2019;17(1):2. Published 2019 Jan 11. 10.1186/s12916-018-1234-0 [DOI] [PMC free article] [PubMed]
- 7.Gonzalez D, Karpman M, Kenney GM, Zuckerman S. Delayed and forgone health care for nonelderly adults during the COVID-19 Pandemic. Urban Institute; 2021. [Google Scholar]
- 8.Rose GL, Bonnell LN, Clifton J, Natkin LW, Hitt JR, O’Rourke-Lavoie J. Outcomes of delay of care after the onset of COVID-19 for patients managing multiple chronic conditions. J Am Board Fam Med. 2022;35(6):1081-91. [DOI] [PubMed] [Google Scholar]
- 9.Felida N, Rogers TB. Gay, lesbian, or bisexual health care access. AAMC Workforce Studies Data Snapshot. May 2022. https://www.aamc.org/media/60791/download. Accessed 1 July 2023
- 10.Durso LE, Baker K, Cray A. LGBT communities and the affordable care act. The Center for American Progress; 2013. [Google Scholar]
- 11.Dahlhamer JM, Galinsky AM, Joestl SS, Ward BW. Barriers to health care among adults identifying as sexual minorities: a US national study. Am J Public Health. 2016;106(6):1116-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Koma W, Rae M, Ramaswamy A, Neuman T, Kates J, Dawson L. Demographics, insurance coverage, and access to care among transgender adults. The Kaiser Family Foundation. 2020. https://www.kff.org/affordable-care-act/issue-brief/demographics-insurance-coverage-and-access-to-care-among-transgender-adults/. Accessed 1 July 2023
- 13.Hsieh N, Ruther M. Despite increased insurance coverage, nonwhite sexual minorities still experience disparities in access to care. Health Aff. 2017;36(10):1786-94. [DOI] [PubMed] [Google Scholar]
- 14.Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-rex Relationships, 2000–2007. Am J Public Health. 2010;100(3):489-95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Tabler J, Schmitz RM, Charak R, Propst A. Forgone care among LGBTQ and non-LGBTQ Americans during the COVID-19 pandemic: the role of health, social support, and pandemic-related stress. South Med J. 2022;115(10):752-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Heck JE, Sell RL, Gorin SS. Health care access among individuals involved in same-sex relationships. Am J Public Health. 2006;96(6):1111-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Bosworth A, Turrini G, Pyda S, Strickland K, Chappel A, De Lew N, Sommers BD. Health insurance coverage and access to care for LGBTQ+ individuals: current trends and key challenges. Assistant Secretary for Planning and Evaluation. 2021. https://aspe.hhs.gov/sites/default/files/2021-07/lgbt-health-ib.pdf. Accessed 1 July 2023
- 18.Gruberg S, Mahowald L, Halpin J. The state of the LGBTQ community in 2020. Center for American Progress; 2020. [Google Scholar]
- 19.Casey LS, Reisner SL, Findling MG, Blendon RJ, Benson JM, Sayde JM, Miller C. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54 Suppl 2(Suppl 2):1454-66. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. [Google Scholar]
- 21.Waters E, Pham L, Convery C. A crisis of hate: a report on lesbian, gay, bisexual, transgender, and queer hate violence homicides in 2017. National Coalition of Anti-Violence Programs (NCAVP); 2018. http://avp.org/wp-content/uploads/2018/01/a-crisis-of-hate-january-release-12218.pdf. Accessed 1 July 2023
- 22.Movement Advancement Project. Equality maps: healthcare laws and policies. 2023. Available from: https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies. Accessed 1 Oct 2024
- 23.FINRA Investor Education Foundation [Internet]. Gauging the state of financial capability in the U.S. Available from: https://finrafoundation.org/knowledge-we-gain-share/nfcs. Accessed 2 Jan 2023
- 24.Human Rights Campaign. 2021 state equality index: a review of state legislation affecting the lesbian, gay, bisexual, transgender and queer community and a look ahead in 2022; 2022. https://reports.hrc.org/2021-state-equality-index-2#2021-state-scorecards. Accessed 2 Jan 2023
- 25.Singh S, Durso LE. Widespread discrimination continues to shape LGBT people’s lives in both subtle and significant ways. Center for American Progress; 2017. [Google Scholar]
- 26.Romero AP, Goldberg SK, Vasquez LA. LGBT people and housing affordability, discrimination, and homelessness. The Williams Institute; 2020. [Google Scholar]
- 27.Bolibol A, Buchmueller TC, Lewis B, Miller S. Health insurance coverage and access to care among LGBT adults, 2013-19. Health Aff. 2023;42(6):858-65. [DOI] [PubMed] [Google Scholar]
- 28.Stevens SD. Obesity in sexual and gender minority populations: prevalence and correlates. Curr Obes Rep. 2023;12(2):175-82. [DOI] [PubMed] [Google Scholar]
- 29.Corliss HL, Vankim NA, Jun H-J, Austin SB, Hong B, Wang M, Hu FB. Risk of type 2 diabetes among lesbian, bisexual, and heterosexual women: findings from the nurses’ health study II. Diabetes Care. 2018;41(7):1448-54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Deraz O, Caceres B, Streed CG Jr, et al. Sexual minority status disparities in life's essential 8 and life's simple 7 cardiovascular health scores: a french nationwide population-based study. J Am Heart Assoc. 2023;12(11):e028429. 10.1161/JAHA.122.028429 [DOI] [PMC free article] [PubMed]
- 31.Caceres BA, Brody A, Luscombe RE, Primiano JE, Marusca P, Sitts EM, Chyun D. A systematic review of cardiovascular disease in sexual minorities. Am J Public Health. 2017;107(4):e13-e21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Walters ML, Chen J, Breiding MJ. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Findings on Victimization by Sexual Orientation. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2013. [Google Scholar]
- 33.Dickman SL, Himmelstein G, Himmelstein DU, Strandberg K, McGregor A, McCormick D, Woolhandler S. Uncovered medical bills after sexual assault. N Engl J Med. 2022;387(11):1043-4. [DOI] [PubMed] [Google Scholar]
- 34.Mirza SA, Rooney C. Discrimination prevents LGBTQ people from accessing health care. The center for american progress; 2018. https://www.americanprogress.org/article/discrimination-prevents-lgbtq-people-accessing-health-care/. Accessed 1 July 2023
- 35.Gavulic KA, Gonzales G. Health care expenditures and financial burden: a comparison of adults in same-sex couples and different-sex couples. Med Care Res and Rev. 2022;79(2):281-9. [DOI] [PubMed] [Google Scholar]
- 36.Weigel G, Ranji U, Long M, Salganicoff A. Coverage and use of fertility services in the U.S.: Kaiser Family Foundation; 2020. https://www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s/. Accessed 1 July 2023
- 37.Nahata L, Quinn GP, Caltabellotta NM, Tishelman AC. Mental health concerns and insurance denials among transgender adolescents. LGBT Health. 2017;4(3):188-93. [DOI] [PubMed] [Google Scholar]
- 38.Solotke MT, Liu P, Dhruva SS, Gulanski B, Shah ND, Ross JS. Medicare prescription drug plan coverage of hormone therapies used by transgender individuals. LGBT Health. 2020;7(3):137-45. [DOI] [PubMed] [Google Scholar]
- 39.Padula WV, Baker K. Coverage for gender-affirming care: making health insurance work for transgender Americans. LGBT Health. 2017;4(4):244-7. [DOI] [PubMed] [Google Scholar]
- 40.Varney S. HIV preventative care is supposed to be free in the US. So, why are some patients still paying?: the Kaiser Family Foundation; 2022. https://kffhealthnews.org/news/article/prep-hiv-prevention-costs-covered-problems-insurance/. Accessed 1 July 2023
- 41.Nguyen KH, Levengood TW, Allen HL, Gonzales G. Health insurance coverage and access to care by sexual orientation during the COVID-19 pandemic: United States, January 2021-February 2022. Am J Public Health. Jan 2024;114(1):118-128. 10.2105/ajph.2023.307446. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Tran NM, Mann S, Gonzales G. Sexual orientation, high-deductible health plans, and financial barriers to care. Health Aff (Millwood). 2023;42(9):1283-1288. 10.1377/hlthaff.2023.00201. [DOI] [PubMed] [Google Scholar]
- 43.Galbraith AA, Soumerai SB, Ross-Degnan D, Rosenthal MB, Gay C, Lieu TA. Delayed and forgone care for families with chronic conditions in high-deductible health plans. J Gen Intern Med. 2012;27(9):1105-11. 10.1007/s11606-011-1970-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Spivack SB, Murray GF, Rodriguez HP, Lewis VA. Avoiding Medicaid: characteristics of primary care practices with no Medicaid revenue. Health Aff. 2021;40(1):98-104. 10.1377/hlthaff.2020.00100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Gonzales G, Ehrenfeld J. The association between state policy environments and self-rated health disparities for sexual minorities in the United States. Int J Environ Res Public Health. 2018;15(6):1136. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Gonzales G, Tran NM, Bennett MA. State policies and health disparities between transgender and cisgender adults: considerations and challenges using population-based survey data. J Health Polit Policy Law. 2022;47(5):555-81. [DOI] [PubMed] [Google Scholar]
- 47.Nelson CL, Wardecker BM, Andel R. Sexual orientation and gender identity-related state-level policies and perceived health among lesbian, gay, bisexual, and transgender (LGBT) older adults in the United States. J Aging Health. 2023;35(3-4):155-167. 10.1177/08982643221116762 [DOI] [PubMed]
- 48.White BP, Abuelezam NN, Fontenot HB, Jurgens CY. Exploring relationships between state-level LGBTQ inclusivity and BRFSS indicators of mental health and risk behaviors: a secondary analysis. J Am Psychiatr Nurses Assoc. 2023;29(3):224-231. 10.1177/10783903211007900 [DOI] [PubMed]
- 49.Horberg M, Raymond B. Financial policy issues for HIV pre-exposure prophylaxis. Am J Prev Med. 2013;44(1):S125-S128. 10.1016/j.amepre.2012.09.039. [DOI] [PubMed] [Google Scholar]
- 50.Badgett MVL, Carpenter CS, Sansone D. LGBTQ economics. J Econ Perspect. 2021;35(2):141-170. 10.1257/jep.35.2.141 [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are publicly available at the following URL: https://www.finrafoundation.org/data-and-downloads.