Each June, Pride Month celebrates the strength and resilience of the ever-growing lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) communities across the United States. It’s a joyful reminder of the immense progress that’s been made to ensure LGBTQ+ visibility and inclusion, as well as a call to action for the continued work needed to ensure the community can thrive. 

LGBTQ+ people face well-documented health disparities and inequities compared to their cisgender, heterosexual peers, and are more likely to live below the poverty line and be enrolled in Medicaid. Federal agencies have begun prioritizing efforts to protect LGBTQ+ health care access and are encouraging Medicaid agencies to collect sexual orientation and gender identity (SOGI) data. However, persistent homophobia and transphobia, as well as increasing political polarization around LGBTQ+ health issues, can make it challenging for Medicaid policymakers to effectively serve this community.

This blog post shares three Medicaid policy opportunities to better support LGBTQ+ health, with a focus on LGBTQ+ health equity. It draws from conversations with LGBTQ+ serving health care providers, LGBTQ+ Medicaid members, and state Medicaid policymakers.

Policy Opportunities to Improve LGBTQ+ Health Care Access and Services

1. Increase the Number of LGBTQ+ Competent Providers

Staffing shortages among Medicaid providers is an ongoing challenge. As noted across interviews, the existing provider shortage is further exacerbated for LGBTQ+ Medicaid members seeking culturally competent care, especially among primary care and behavioral health providers. Culturally competent care — which avoids biases and incorporates individuals’ beliefs, preferences, experiences, and needs — is an important part of LGBTQ+ communities feeling safe accessing health services and receiving appropriate care.

A lack of access to LGBTQ+ competent providers disproportionately impacts LGBTQ+ people with marginalized intersecting identities, such as youth and Black, Indigenous, and people of color (BIPOC), exacerbating health disparities. When patients experience discrimination from health care providers, it can lead to delayed care or worse health outcomes and ultimately further compound inequities among these communities.

To improve access to LGBTQ+ competent providers, Medicaid agencies can consider partnering with community organizations to implement provider trainings around LGBTQ+ competencies, like the Ruth Ellis Institute in Michigan or Whitman-Walker Institute in Washington, D.C., or offer continuing education credits around LGBTQ+ cultural competencies for health care staff. Medicaid agencies can also create or use existing directories as a resource for members to access providers who are trained in LGBTQ+ competencies, such as the LGBTQ+ Healthcare Directory, which includes a list of providers who offer LGBTQ+ competent care.

2. Improve Access to Covered Services for LGBTQ+ Populations

Some state Medicaid agencies cover aspects of gender-affirming care and other services specific to the LGBTQ+ community. Unfortunately, this coverage does not always ensure access and uptake. Staffing shortages noted above create longer wait times and limit access to services. This can be even more harmful for LGBTQ+ Medicaid members seeking time sensitive services, like refilling prescriptions for hormone replacement therapy.

Further, some Medicaid processes create hurdles for members to get the care they need. For example, a letter of support or a referral is commonly needed for individuals to receive prior authorization for gender-affirming care services. Medicaid programs are not always clear on what information is needed in these documents, making it difficult for providers to complete them correctly. In addition, some members, especially youth, are not aware of the gender-affirming care coverage that Medicaid offers, causing them to not seek out those services.

One strategy to improve access to covered gender-affirming services is by promoting the use of LGBTQ+ care navigators. For example:

• Philadelphia FIGHT, a community health center that operates with support from grants, Medicaid, and private insurers, provides comprehensive health services to people living with HIV/AIDS and those at high risk. The center offers Pride Navigators to patients, helping them get connected to LGBTQ+ competent providers.
• Veteran’s Affairs health systems are required to have a LGBTQ+ Veteran Care Coordinator (LGBTQ+ VCC) to help veterans get affirming care.

When it comes to the complexities of Medicaid processes, providers noted that it would be helpful for state Medicaid agencies to offer clearer guidance or an easy-to-follow template for writing a referral or a letter of support for members seeking gender-affirming care services. Colorado’s billing guide to help hospital and health center billing staff properly code gender-affirming care is a great example for other states to consider. Medicaid agencies can also develop simplified explanation of benefits to help members better understand the services they are eligible for.

3. Develop Comprehensive SOGI Data Collection and Reporting Guidelines

Collecting robust, comprehensive SOGI data is critical to understanding the needs of the LGBTQ+ community and providing appropriate, culturally responsive, and equitable care. The Centers for Medicare & Medicaid Services (CMS) recently introduced three optional SOGI questions in its model application that state Medicaid and CHIP agencies can add to their state-specific enrollment application.

While this guidance from CMS is an important step, interviewed policymakers discussed struggling to develop guidelines related to SOGI data collection and reporting. In particular, policymakers expressed concern around SOGI data proxy reporting, fearing it could result in inaccurate data. Proxy reporting is when a person provides health-related information on behalf of other individuals, most often impacting youth, older adults, and people with disabilities. To ensure more complete SOGI data collection, Medicaid agencies can consider developing guidance to encourage SOGI data collection by proxy in addition to self-reporting, as research shows SOGI questions are no more difficult to answer by proxy than other sensitive non-SOGI items (e.g., disability, income, or employment).

Policymakers also noted pushback they’ve received from providers, health plans, and licensing boards about SOGI data collection, citing that providers lack training on how to ask SOGI-related questions, and state systems lack interoperability for SOGI information to be stored and compared across federal programs. Proxy reporting guidance can be part of larger Medicaid efforts to routinely capture and use SOGI data in clinical settings. To encourage these efforts, states can consider looking to federal grant funding or using waiver submission requests to fund data collection and storage systems updates for SOGI data, provide staff trainings, and communicate with members that providers will be asking SOGI-data related questions. States can look to Oregon’s SOGI data collection workgroup as a way to incorporate lived experience into the SOGI data policymaking process. These innovations can help to normalize SOGI data collection, and ultimately give state agencies the information they need to better address disparities that impact the LGBTQ+ population.

Looking Forward

Medicaid agencies play an important role in advancing LGBTQ+ health and health equity. States have a growing number of policy levers available to them to improve access and quality of care for the LGBTQ+ population. It is critical that programs and services are continuously iterated on to better meet the diverse and unique needs of every LGBTQ+ individual, in partnership with LGBTQ+ people and the providers that serve them.