Hours after his Inauguration, President Donald Trump signed an executive order aimed at "minimizing the economic burden" of the Affordable Care Act (ACA) "pending repeal." And if the ACA, also known as "Obamacare," is repealed—or partially repealed—the LGBTQ community could be disproportionately impacted.
An estimated 18 million Americans could lose their health insurance coverage if even a partial repeal of the ACA goes forward, according to a nonpartisan report filed by the Congressional Budget Office (CBO), and as many as 32 million could become uninsured in the next 10 years as Medicaid expansions and subsidies are eliminated. The CBO report predicts that ending the mandate penalty alone will cause the cost of insurance to skyrocket, as younger and healthier people opt out of insurance, and the composition and health status of the insured shifts. Premiums could initially increase by 20 to 25 percent and double by 2026, according to the findings.
Members of the LGBTQ community would be overrepresented among these millions to lose their coverage and may also lose access to other benefits of the ACA, such as non-discrimination protections, if the Trump administration changes or fails to enforce existing regulations.
"The Affordable Care Act brought relief to millions—whether it's those living with pre-existing conditions like HIV/AIDS or trans people who are now able to access necessary care. Countless LGBTQ people are now living in fear that we will go back to the days where one illness can mean not only financial but physical ruin," David Stacy, Government Affairs Director at the Human Rights Campaign, told NBC Out.
Loss of Coverage
According to Jen Kates, Vice President and Director of Global Health and HIV Policy at the Kaiser Institute, the ACA has made a "significant difference" for the LGBTQ community. "The ACA actually decreased the uninsured rate among LGBTQ folks more than other populations," Kates told NBC Out. In a study by the Urban Institute, researchers estimated the percentage of uninsured lesbian, gay and bisexual adults fell from 28 percent to 11 percent between June 2013 and March 2015.
Medicaid is the single largest source of health coverage for those who are living with HIV in the U.S., according to the Kaiser Institute. Accessing health care before the ACA was difficult if not impossible if one had HIV, Kates explained. "HIV was a deniable condition. If they were able to get access, it was unaffordable, because rate settings were based on health status. You could hit your annual or lifetime caps," she said.
The ACA prohibits these cost caps, and allows individuals to receive Medicaid based only on income qualifications. Previously, HIV-positive individuals had to wait until their illness was debilitating to be "categorically eligible" for Medicaid. "Now people don't have to face that barrier," Kates said. She also explained that the ACA "has taken the edge off" the Ryan White HIV/AIDS federal grant program, which provides funds to states and cities to insure those who are HIV positive by helping to "fill the funding gap." If Medicaid funding disappears, those who are HIV positive and low-income would once again have to rely on that program or lose their care entirely.
Fate of Non-Discrimination Protections
LGBTQ people have long faced discrimination in the provision of medical services. Prior to the passage of the ACA, "59 percent of low- and middle-income trans people did not have health insurance. Not because they didn't want it, but because being trans itself was considered a pre-existing condition," Katie Keith told NBC Out. Keith is a Steering Committee Member of Out2Enroll, an organization that conducts outreach to LGBTQ people to encourage them to enroll under the Affordable Care Act.
Section 1557 of the ACA prohibits discrimination on the basis of "race, color, national origin, sex, age, or disability" in any program that receives federal funding. The Obama administration has interpreted this clause to include gender identity and sex stereotyping. As a result, programs and providers are prohibited from denying services to an individual on the basis of their trans identity and must provide treatment consistent with their gender identity.
"If a full repeal happens, those protections would just go away," Kates said. For Kates, the non-discrimination protections have had "a big impact" on the LGBTQ community—this is where repeal would be felt the most.
The bottom line is that "the ACA is working for LGBT people," Keith said. "If Congress is going to go forward with this, they need to tell us what the plan is." Keith remained committed to the idea that the more people who enroll, the harder it will be fore Congress to dispense with the ACA entirely. Open enrollment continues until January 31, and regardless of what Congress does in the next few weeks, "one of the most important things to do if they don't have health care is to enroll," she added.
Julie Moreau is a Post Doctoral Research Fellow in the Department of Women's, Gender and Sexuality Studies at Washington University in St. Louis. She tweets at @JEMoreau.