Whenever societal progress is made, it should be celebrated. But what is often forgotten with progress is what is yet to be done. Health care coverage for the LGBTQ+ community is one of many examples of societal change. Considering how homosexuality was initially classified as a crime and then a mental illness, significant progress has been made in society’s perception (1). 

Still, the U.S. is not yet at a point where the gap in health care access has been closed for the LGBTQ+ community. So the progress made should be acknowledged, but the incompleteness should be as well. The gap from total health equity for this community is almost closed on a surface level, with legal protections against coverage discrimination. However, there are still inequities rooted in the healthcare system and in the minds of corporations and other health institutions. For example, a 2020 study found that heterosexual individuals were more likely than all sexual minorities to have some sort of health care insurance coverage (2).

Speaking of the accomplishments that advocates have helped achieve, there are now legal protections in place to prevent discrimination against the LGBTQ+ community in health care. Programs that receive federal funding, such as Medicare and Medicaid, are specifically prohibited from increasing prices or denying coverage for members of this identity group (3). This was done under the Affordable Care Act, which encompasses both discrimination based on sexual orientation as well as gender identity (6).

Yet with this progress, change still needs to be made. One in eight members of the LGBTQ+ community report at least one instance of health care discrimination (6). Transgender health care especially remains an area of controversy. In the past, many health insurance policies excluded transgender care, such as coverage for gender-affirming surgery (9). At present, it is illegal for all public and some private insurance companies to deny coverage when the transition surgery is medically necessary.

However, that leaves open the determination of when it is deemed “medically necessary.” Many groups categorize this as when someone is experiencing gender dysphoria, which is a medical diagnosis covering the distress experienced when there is a discrepancy between one’s assigned sex and expressed gender (4). Many insurance policies will give coverage for gender-affirming treatments with a diagnosis of gender dysphoria. However, not all transgender people have gender dysphoria, which can limit their options for surgeries, hormonal changes, and more. It is unclear what percentage of transgender people experience gender dysphoria. Each experience is different, and many individuals do not disclose their experiences due to fear of backlash or discrimination. Therefore, providing coverage only with a diagnosis can limit access to those not suffering from or not disclosing their gender dysphoria.

The process for receiving health insurance coverage as a transgender person is also quite complicated, even if coverage is guaranteed in the end. Certain plans, mostly private plans, still have exclusions for transition-related care due to being out of date or requiring proof it is medically necessary (6). To receive coverage for this care, there must be personal advocacy to the insurance company to remove the exclusion or a determination that it is necessary. This has been done by members of the LGBTQ+ community, but it is not always successful and should not be necessary to receive equitable care. Transgender people are also overall less likely to have health insurance than heterosexual people (8). Obstacles to coverage like this can limit access to health care needs for the LGBTQ+ community.

A lot of variation exists based on state policies, which determine the restrictions for private insurance companies. As of 2022, some states such as New York and California protect the LGBTQ+ community from any discrimination from private insurance companies (3). But other states, such as Arkansas, prohibit insurance coverage of gender-affirming care and offer no legal protection for the rest of the community. The issue of healthcare coverage for LGBTQ+ youth is also controversial in this regard, as many states see it as a crime to provide gender-affirming care to minors. 

The variation between states is striking, and there are community members across the country that cannot access the full protection the Affordable Care Act provides for publicly-funded groups. Projects such as the LGBTQ State Exchanges Project have been launched to work on state expansion of the Affordable Care Act; education, outreach, and enrollment initiatives are being enacted to encourage change (2).

Significant changes have come about since the 1800s when homosexuality was a crime, but U.S. policy has not come far enough to guarantee equal health care for all. There is a clear variation between states on what is deemed a necessary part of medical care. Gender and sexual minorities also do not have access to enough providers that are trained in culturally competent care (7). Many members of the LGBTQ+ community face challenges trying to access coverage for their health care needs. The country can celebrate the progress made and still acknowledge the continuing need for action. The next step in health policy for this minority group is to standardize and increase access to care. This is necessary to prevent discrimination in every state and provide the same opportunity for coverage as non-minority patients. It will also be another step towards closing the gap, and when that time comes, it too will be celebrated.