The U.S. population is rapidly aging. Likewise, older adults who identify as lesbian, gay, bisexual, transgender, queer, and additional sexual and gender identities (LGBTQ+) are also a rapidly growing population. Currently there are an estimated 2.7 million older adults (ages 50 and over) who identify as LGBTQ+, and this number is expected to exceed five million by 2060. LGBTQ+ people often face unique obstacles as they age that impact health and well-being. These challenges are caused by a long history of discrimination, social stigma, isolation, and a policy context that restricts the rights of LGBTQ+ people. These circumstances place LGBTQ+ older adults at heightened risk for a myriad of adverse physical, mental, and social outcomes — with transgender older adults and LGBTQ+ older adults who are Black, Latino, or Indigenous facing even greater risks.

This brief, developed by the Center for Health Care Strategies with support from the California Health Care Foundation, highlights key insights about the health and related social needs of LGBTQ+ older adults to inform state policymakers and other partners. It details opportunities for using Medicaid to improve health and social care for the LGBTQ+ community. It also examines unique opportunities to support aging LGBTQ+ individuals through California’s Medi-Cal reform efforts under the state’s CalAIM initiative.

9 Key Insights About the Health and Social Needs of LGBTQ+ Older Adults

To improve health outcomes for the LGBTQ+ older adult population, it is critical to understand their unique challenges in accessing care and services. Following are key insights into why this population is at higher risk for poor health and social outcomes when compared to cisgender, heterosexual individuals, which can help inform policies to better address the needs of LGBTQ+ older adults.

1. LGBTQ+ older adults have worse health outcomes than their cisgender, heterosexual counterparts.

LGBTQ+ older adults face barriers to receiving formal health care that are not an issue for cisgender, heterosexual adults. Discrimination against LGBTQ+ older adults in health care settings is systemic, in part caused by: (1) a lack of cultural competency training for providers; (2) an almost non-existent focus on the needs of LGBTQ+ older adults in medical training; and (3) problems with electronic health records that may mis-gender or exclude records of gender-affirming care for transgender people. LGBTQ+ older adults also have higher rates of disability and disease compared to cisgender, heterosexual older adults.

2. Discrimination in the health care system can have negative impacts on the mental and cognitive health of LGBTQ+ older adults.

Systemic discrimination creates an environment where many LGBTQ+ individuals are unsure if it is safe to come out to those around them, and additionally creates fears of discrimination and violence. Because coming out is a continual, lifelong process, the stress associated with environmental uncertainty leads to higher rates of anxiety, depression, and substance use disorder among LGBTQ+ older adults. These outcomes can also be caused by the bias of individual providers, who may be untrained in effective communication with LGBTQ+ patients or who have homophobic or transphobic views.

For LGBTQ+ older adults with dementia, the intersection of age, cognitive status, and sexual identity can often lead to compounded marginalization that makes it difficult to find providers equipped to deliver high quality care to these patients. Among transgender older adults, the pressure to conceal their gender identities has been found to be detrimental to attainment of basic psychological needs. LGBTQ+ older adults, and especially those who are transgender, are also significantly more likely to experience cognitive impairment and depressive symptoms, compared to cisgender, heterosexual people.

3. Historic and systemic discrimination can result in lower access to social supports in late life.

LGBTQ+ older adults have fewer social supports as they age, compared to their cisgender, heterosexual counterparts. Same-sex marriage was illegal in most states before 2015 and same-sex parenting has a history of similar legal barriers. As a result, LGBTQ+ older adults are twice as likely to be single, four times less likely to have children, and thus, more likely to live alone as they age. As with all aging people, robust social and familial supports serve as a protective factor for LGBTQ+ older adults’ physical and mental health. A survey of LGBTQ+ Americans found that about 40 percent of LGBTQ+ older adults report having been rejected by their families or friends due to their sexual and/or gender identity, and that 32 percent of LGBTQ+ older adults expressed concern about loneliness and growing old alone, in comparison to 19 percent of non-LGBTQ+ older adults. Notably, the lack of social supports experienced by many LGBTQ+ older adults may put them at great risk for experiencing dementia.

4. Specific groups of LGBTQ+ older adults are more vulnerable to poor physical and mental health outcomes.

While LGBTQ+ individuals of all racial and ethnic groups are equally as likely to worry about how their sexual and/or gender identity may impact the quality of care they receive, Black and Latino community members have the added concern of how their race or ethnicity will impact the quality of care they receive, which in turn can lead to avoidance of care and important discussions with providers on sexual and gender identities. This avoidance is also prevalent among disabled LGBTQ+ older adults. Research from the Center for American Progress found that nearly 14 percent of LGBTQ+ adults with a disability avoid doctors’ offices, versus just over four percent for nondisabled respondents. For transgender older adults of color, social and economic marginalization frequently compound health disparities, leading to increased rates of HIV infection, drug abuse, and suicide attempts. Additionally, intersex older adults, or persons born with sex characteristics that do not fit binary male or female bodies, are often marginalized socially and face adverse health care experiences. A study of intersex older adults found that they had far worse self-reported health and greater functional difficulties than the general population.

5. LGBTQ+ discrimination occurs in long-term care facilities, assisted living, and housing.

Despite federal laws prohibiting discrimination on the basis of sexual orientation or gender identity in nursing homes or any Medicaid- or Medicare-funded services, LGBTQ+ older adults experience discrimination and abuse in both nursing homes and assisted living facilities. LGBTQ+ adults in nursing home environments report being denied the ability to live together with their partner, not being allowed to have chosen family members participate in their medical decision-making, and experiencing homophobic or transphobic remarks and hostility from both staff members and fellow residents. In a survey of LGBTQ+ older adults living in a long-term care facility, 89 percent of respondents believed that a staff member would discriminate against an openly LGBTQ+ resident, and 77 percent reported that other residents would not socialize with an LGBTQ+ resident. As such, LGBTQ+ adults in long-term care facilities may find themselves hiding their sexual and/or gender identities to avoid potential discrimination and rejection from staff and fellow residents. For transgender older adults, many of whom cannot conceal their gender identity, the need for physical assistance in activities of daily living in long-term care facilities, such as with showering, getting dressed, or being fed, result in increased safety concerns and risks for physical abuse.

6. LGBTQ+ older adults face barriers to accessing home- and community-based services.

Home- and community-based services (HCBS), which include non-medical services such as transportation, assistance with activities of daily living, meals, and other supports, are critical for older adults to age in place in the communities they love and avoid expensive institutional care. LGBTQ+ older adults face unique barriers to accessing HCBS. A needs assessment conducted in San Francisco — widely recognized as one of the nation’s most LGBTQ+-friendly cities — found that LGBTQ+ older adults faced challenges such as having to choose lower quality services due to a lack of inclusivity in HCBS. Despite the high cost of HCBS, these services are often not inclusive or are inherently discriminatory in design, creating barriers to high-quality and person-centered care for this population. Coexistent with this discrimination is a lack of funding and resources for community-based LGBTQ+ older adult centers, with only two percent of all federal grants, seven percent of all state grants, and nine percent of all local grants over $10,000 dedicated to programs for LGBTQ+ older adults as of 2015.

7. LGBTQ+ older adults face housing discrimination.

Older populations face numerous housing challenges, including those related to affordability and physical accessibility. These challenges are exacerbated for LGBTQ+ older adults who also face discrimination due to their sexual or gender identities, with LGBTQ+ older adults experiencing homelessness at disproportionally high rates. While the federal Fair Housing Act aims to prohibit housing discrimination based on race, color, national origin, religion, sex, familial status, and disability, it currently does not protect LGBTQ+ people. In one survey, nearly one-in-three LGBTQ+ older adults reported being worried about having to hide their sexual and/or gender identity to enable access to suitable housing options. There are still documented discriminatory practices in the housing sector, with housing providers often quoting higher fees, rental prices, and more complicated application requirements for LGBTQ+ people, as well as housing providers offering fewer, if any, units to LGBTQ+ applicants in comparison to non-LGBTQ+ applicants. In response, some organizations have built LGBTQ+-friendly low-income housing units, however, these are rare and tend to be accessible only in certain urban areas.

8. Aging in rural areas creates unique challenges for LGBTQ+ older adults.

LGBTQ+ older adults living in rural settings often experience unique health care challenges. One key issue for LGBTQ+ older adults in these settings is finding a culturally competent and affirming health care provider. For transgender and non-binary rural residents, the fear of being discriminated against in health care settings is associated with worse self-reported health, high prevalence of chronic conditions, and lower utilization of health care. Another challenge is that many rural areas are less likely to have key legal protections against discrimination, which extends to protections for employment, housing, and health care; against conversion therapy; and for gender identity changes on key documents for transgender people (e.g., driver’s license and birth certificate). Additionally, finding support systems for LGBTQ+ older adults in rural settings can be particularly challenging. A 2018 survey from AARP found that only 11 percent of LGBTQ+ older adults living in rural communities had access to an LGBTQ+ health center, in comparison to 57 percent of those living in urban areas.

9. LGBTQ+ older adults often experience economic insecurity and use Medicaid services.

Financial instability and legal issues are major concerns among LGBTQ+ older adults. Lifetime disparities in earnings, employment, and opportunities to build wealth, as well as discriminatory barriers to legal and social programs that traditionally support aging adults, put LGBTQ+ older adults at greater financial risk than their non-LGBTQ+ peers. One-third of LGBTQ+ older adults live at or below 200 percent of the federal poverty level (FPL). Transgender older adults face even greater economic insecurity, with 48 percent reporting living at our below 200 percent FPL. Additionally, one study showed that intersex older adults are more likely to live with lower incomes — one-in-four respondents reported that they lived with an income below $20,000 per year.  While 1.2 million LGBTQ+ older adults are estimated to be covered by Medicaid, incomplete and/or inaccurate sexual orientation and gender identity (SOGI) data may contribute to this estimate being lower than the actual amount of LGBTQ+ older adults using Medicaid.

Key Opportunities to Use Medicaid to Improve Health and Social Care for LGBTQ+ Older Adults

Since LGBTQ+ older adults are likely to have lower incomes qualifying them for Medicaid services, there are opportunities for states, MCPs, and providers across the country to design Medicaid programs to better meet their needs. Following are key opportunities for leveraging Medicaid to improve services for LGBTQ+ older adults in California, as well as in states across the nation.

• Contract with CBOs to provide culturally responsive care to LGBTQ+ communities. Under CalAIM, for example, one of the goals of requiring MCPs to contract with CBOs for ILOS is to ensure that enrollees are getting culturally responsive care. MCPs should identify and seek out partnerships with social service organizations that cater to the needs of the LGBTQ+ community, addressing needs such as housing, care management, and other social services. For example,in the housing sector, organizations such as Openhouse in San Francisco are a trusted source of housing navigation for LGBTQ+ older adults. Openhouse has had a significant positive effect on LGBTQ+ older adults’ lives by helping to increase community connectedness and reduce social isolation.

• Promote provider trainings and organizational-level changes within long-term care to improve LGBTQ+ inclusive care. LGBTQ+ populations have a wide variety of needs that are often hidden for fear of discrimination. As such, MCP-supported trainings for individual providers are integral to developing a compassionate and understanding workforce that allows LGBTQ+ older adults to feel comfortable accessing care and resources. Organizations, such as Openhouse and New-York based PHI, have received state grants to develop trainings for providers that focus on understanding how life experiences, health disparities, and barriers to care come together to affect the health care experience of LGBTQ+ older adults. At the provider level, the Human Rights Campaign Foundation and SAGE collaborated on a new tool to promote organizational-level change in residential long-term care (LTC) organizations called the Long-Term Care Equality Index (LEI). Providers can sign a Commitment to Care Pledge, take a confidential LEI self-assessment, and receive support for developing LGBTQ+-inclusive policies and goals after receiving a customized needs-assessment report.

• Create LGBTQ+ inclusive LTC policies. In recent years, some states have made progress in expanding and specifying LGBTQ+-inclusivity in LTC. While federal laws, such as the Equality Act, exist to make discrimination illegal for LGBTQ+ people in LTC, supportive state legislation and regulations can be much more specific in the types of protections needed by LGBTQ+ older adults. Some new state actions, in states such as California and Massachusetts, include:
  • Prohibiting denial of admission, service, medical care, and reasonable accommodations due to sexual orientation, gender identity, and expression, intersex status, or HIV status.
  • Requiring cultural competency training for LTC facility administrators and staff members.
  • Developing LGBTQ+ bill of rights that include the right of residents to use their chosen names, pronouns, and clothing. New Jersey and California have enacted such laws for LGBTQ+ and HIV positive residents. (See the California Bill of Rights below.)

• Support the development of LGBTQ+ friendly supportive housing and assisted living communities. As the U.S. population ages, many states are making efforts to invest in housing for older adults. California for example has invested $570 million in its Community Care Expansion Program to both rehabilitate and develop new supportive housing, with $53 million awarded for creating more residential care options for low-income older adults and adults with disabilities. The state has also increased investment in Assisted Living Waiver slots in which Medi-Cal pays for enrollees who need long-term services and supports. This development offers an opportunity to create welcoming and inclusive spaces for LGBTQ+ older adults. To support such efforts, the National LGBTQ+ Housing Initiative provides technical assistance to developers and housing organizations to support inclusive housing policy and development of LGBTQ+ friendly housing across the country.

 

• Work across sectors to improve collection of SOGI data to support more effective care delivery. SOGI data and accurate history of gender-affirming care are both crucial information for providers to ensure delivery of essential important health and social care. An analysis of electronic health records from one MCP found that for transgender and gender diverse people, only 48 percent had current SOGI information that accurately represented their identities in the electronic health record.  State Medicaid agencies, MCPs, and providers involved in members’ care (including medical, care management, CBOs, housing, and other providers) can work together to improve the systematic collection and sharing of SOGI data to ensure members are given appropriate care and referred to culturally responsive services.

Conclusion

Both within California and on a national level, LGBTQ+ older adults struggle with unmet health and social needs due to systemic factors, which can result in a lifetime of health disparities and poor health and social outcomes for this population. States, MCPs, and providers can take action to better address these unmet needs by implementing strategies, such as by improving LGBTQ+ inclusivity in housing and long-term care settings, working across sectors to improve data collection, and developing culturally sensitive trainings to enhance care delivery. Additionally, several unique opportunities exist in California through CalAIM to promote improved care for this population, such as through Community Supports, Enhanced Care Management, and the Institutional Long-Term Care Carve-In.

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