LGBT Health and Well-being
HHS LGBT Issues Coordinating Committee 2015 Report
The U.S. Department of Health and Human Services (HHS) is committed to advancing the equality, health, and well-being of all Americans, including lesbian, gay, bisexual, and transgender (LGBT) individuals and their families. Therefore, the Department is pleased to present notable accomplishments from the past year and highlight HHS’s objectives for the coming year in this fifth annual report on LGBT health and well-being. The Department also wishes to acknowledge the steadfast commitment of colleagues from across HHS, including members of the LGBT Issues Coordinating Committee, who were instrumental in developing this report.
The Department also recognizes that this year marked a watershed moment for LGBT individuals when the U.S. Supreme Court recognized marriage equality across the entire United States in a historic ruling on June 26th. Following the Obergefell v. Hodges decision, HHS coordinated a review of relevant programs and policies to determine what guidance or other action might be needed to help ensure the swift and smooth implementation of the decision. The Department anticipates that those efforts will continue into FY 2016.
FY 2016 Objectives:
1. Connecting Consumers with Quality Care through the Affordable Care Act
Since the passage of the Affordable Care Act (ACA) five years ago, more than 17.6 million uninsured people have gained health coverage, resulting in the largest reduction of uninsured individuals in four decades. At its core, the ACA strives to reduce health inequities, and improve health care access, affordability and quality.
However, the Department recognizes that disparities in health coverage and services for LGBT individuals still exist. In addition, many newly insured individuals are navigating coverage for the first time and may be unsure how to manage health care systems. HHS is committed to implementing the ACA so that its promise is fully realized for everyone and so that consumers are able to become engaged and empowered. We have made great strides towards that goal this year, and we are committed to taking further steps in FY 2016 to improve health care access and enrollment for the LGBT community:
- Non-discrimination protections: Section 1557 - Section 1557, the civil rights provision of the ACA, has been in effect since its enactment. Section 1557 marks the first time that a federal civil rights law has prohibited sex discrimination in health programs or activities, expanding the protections afforded to individuals seeking health care and OCR’s jurisdiction to address discrimination against them. In September 2015, the Office for Civil Rights (OCR) issued a Notice of Proposed Rulemaking (NPRM) entitled, Nondiscrimination in Health Programs and Activities, which incorporates longstanding and familiar civil rights principles. The proposed rule includes discrimination based on gender identity and discrimination based on sex stereotyping in the definition of sex discrimination. As such, the proposed rule specifies that individuals cannot be denied health care or health coverage based on their sex—including their gender identity—and that individuals must be treated consistent with their gender identity, including in access to facilities. The proposed rule also prohibits denial or limitation of sex-specific care just because the person seeking such services identifies as belonging to another gender. Finally, the proposed rule prohibits explicit categorical exclusions of coverage for all health care services related to gender transition. Making clear its commitment, as a matter of policy, to preventing discrimination based on sexual orientation, OCR has solicited comment on how to ensure that the final rule includes the most robust set of protections against discrimination that are supported by the courts on an ongoing basis.
Section 1557 has been in effect since its enactment in 2010. In July 2015, OCR announced its first voluntary resolution agreement under Section 1557, in which The Brooklyn Hospital Center (TBHC) agreed to ensure that transgender patients at TBHC receive appropriate and equitable care and treatment. The voluntary resolution agreement resolved a complaint filed by a transgender individual who alleged discrimination on the basis of sex in the assignment of patient rooms. TBHC committed to revising its Admissions Policy and Procedure to ensure equal access for all patients; implementing an intake process that affords patients an opportunity to provide both their legal name and a preferred name as well as to identify their sex and/or gender; revising its room placement and nondiscrimination policies; and training staff on these policy changes.
OCR plans to issue a final rule implementing Section 1557 in 2016, after considering comments received on the NRPM.
- Gender transition-related care exclusions: As HHS works to ensure that more LGBT people have access to quality, affordable health coverage, we recognize that many transgender individuals are still unable to acquire coverage that adequately meets their needs. Many plans still exclude transition-related care from coverage, whether or not it is determined to be medically necessary by an individual’s provider. The proposed OCR regulation implementing Section 1557 of the ACA would prohibit explicit categorical exclusions in insurance coverage for all health care services related to gender transition or otherwise discriminating against an individual because they are transgender. After the rule is finalized, HHS will disseminate information to issuers highlighting obligations under Section 1557.
- Non-discrimination: Conditions of Participation - By the end of FY 2016, the Centers for Medicare & Medicaid (CMS) expects to issue an NPRM that prohibits discrimination based on sexual orientation or gender identity in the provision of services by participating hospitals and critical access hospitals to patients of Medicare and Medicaid. This NPRM follows the release of guidance in 2011 clarifying the visitation rights of LGBT individuals in Medicare and Medicaid participating hospitals, critical access hospitals, and nursing homes.
- Enhancing Electronic Health Records: As the health care market moves towards streamlined and interoperable methods of collecting and sharing information, we recognize that sexual orientation and gender identity (SOGI) have important health implications, and that processes for sharing that information must be carefully considered and developed. Self-reported sexual orientation and gender identity information collected in electronic health records (EHRs) can be appropriately used to both improve the health care of LGBT individuals and to support the ability to track health outcomes of LGBT individuals in population health. The Office of the National Coordinator for Health Information Technology (ONC) has included requirements for the structured recording of an individual’s sexual orientation and gender identity in the 2015 Edition Health IT Certification Criteria final rule. This requirement is included in the certified EHR technology (CEHRT) definition for the EHR Incentive Programs. Providers may use EHR technology certified to this recording capability to meet the CEHRT definition beginning 2016 and are required to have EHR technology certified to this capability beginning in 2018 to meet the CEHRT definition. The EHR Incentive Programs final rule also specifically emphasizes the inclusion of capabilities to record sexual orientation and gender identity data with certified EHR technology under the EHR Incentive Programs.
- Data Collection in Marketplace Enrollment: The Center for Consumer Information and Insurance Oversight (CCIIO) within CMS will convene a work group to develop a common strategy for the inclusion of SOGI questions in enrollment data. Among other issues, this group will seek to clarify the existing question regarding sex on the federal Marketplace application, provide guidance for state Marketplaces seeking to add SOGI questions to their applications, and explore the feasibility of adding SOGI questions to the federal Marketplace application.
- Cultural Competency for Marketplace-Approved Assisters: CCIIO will provide ongoing LGBT cultural competency training for Marketplace-approved assisters in Federally-facilitated Marketplaces, and will work towards systemic integration of LGBT content into resources and training used for Marketplace consumer support. Specifically, it will continue to educate Navigators, certified application counselors, and non-Navigator assistance personnel through webinar presentations, newsletter updates, and other technical assistance on best practices for reaching and assisting LGBT consumers to help them enroll in coverage through the Marketplaces.
These objectives follow the work that others in the Department have done to encourage and support LGBT enrollment:
In November 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) published Affordable Care Act Enrollment Assistance for LGBT Communities: A Resource for Behavioral Health Providers, which guides health professionals in helping LGBT individuals enroll in health insurance coverage and understand their health insurance options, particularly with regard to mental health and substance abuse benefits and services.
In June 2015, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a report, Outreach and Enrollment for LGBT Individuals: Promising Practices from the Field, which described promising practices for Marketplace and Medicaid outreach and enrollment for LGBT individuals.
2. Institutionalizing an HHS Focus on LGBT Health and Well-Being
In the past five years, HHS has taken significant strides towards advancing the health and well-being of LGBT individuals. Recognizing the importance of continuing to reduce the health disparities experienced by the LGBT community, in FY 2016 the Department will move to further institutionalize this work within the Office of the Assistant Secretary for Health (OASH). OASH currently tracks Departmental progress on LGBT initiatives through Healthy People 2020, and has served as a co-chair of the Committee since its inception in 2010. Consequently, the Office is well-positioned to serve as a home for cross-cutting LGBT policy initiatives at HHS. In January 2016, the Assistant Secretary for Health will host a stakeholder listening session to solicit feedback on how to best institutionalize this work.
3. Developing an LGBT Research Working Group
Acknowledging significant health disparities facing LGBT populations, HHS has taken steps to fill the gaps in research that will help the Department understand how to better meet the needs of LGBT communities. In the coming year, the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), Agency for Healthcare Research and Quality (AHRQ), and other HHS divisions will convene and open a cross-Department dialogue designed to harmonize efforts and prevent duplication with respect to LGBT research.
4. Removing the Gender Marker from the Medicare Card
As part of the initiative to remove Social Security Numbers from the Medicare card, CMS is taking every permissible step to minimize harassment and violations of privacy throughout the process of obtaining health care services, including removing the gender marker in the card redesign process.
5. Advancing Equality in the U.S. Public Health Service Commissioned Corps
In June 2015, the U.S. Surgeon General established the Sexual Orientation and Gender Diversity Advisory Group in the U.S. Public Health Service Commissioned Corps (USPHS). This is the first officially sanctioned group of LGBT public health officers. The Advisory Group creates a safe space within the Corps to discuss issues and concerns unique to LGBT officers and their allies, acknowledges evolving policies and practices relevant to sexual and gender minorities (SGM) at the state and federal levels, and serves as a resource to provide culturally appropriate and medically accurate care to diverse communities. Recognizing the important role of the nation’s doctor, the Advisory Group also will advise the Surgeon General on health issues faced by LGBT individuals.
In addition, the Surgeon General has tasked senior leadership from the Division of Commissioned Corps Personnel and Readiness to work with colleagues from the other uniformed services in reviewing and reforming policies related to transgender individuals in the uniformed services. The Surgeon General is committed to lifting barriers to commissioning transgender individual into the USPHS.
6. Improving HHS Data to Enhance LGBT Health and Well-Being
HHS will develop an issue brief delineating HHS’s strategy and implementation plans to add SOGI questions to national surveys, administrative data systems, and EHRs. This brief will build on the success of previous Departmental efforts and current HHS data enhancements for LGBT health.
FY 2015 Accomplishments:
The following are key accomplishments from this past year in the area of LGBT health and well-being. In addition to reporting on the commitments we made last year, we also highlight several major accomplishments that were not included in the 2014 report.
Enforcing Civil Rights and Nondiscrimination Protections
The Assistant Secretary for Financial Resources continues to work to extend Departmental non-discrimination policies to HHS discretionary grantees. This effort follows the Department’s previous action to eliminate discrimination through guidance in 2011 that established sexual orientation and gender identity-inclusive non-discrimination policies applicable to services provided to HHS program beneficiaries by HHS employees and contractors.
Reaffirming Access to Preventive Services for All Consumers
In May 2015, CMS issued sub-regulatory guidance clarifying that the preventive services available under the ACA are available regardless of an individual’s gender identity, sex assigned at birth, or recorded gender. More specifically, Section 2713 of the Public Health Service Act, as amended by the ACA, requires most health insurance plans to cover certain recommended preventive services at no out-of-pocket cost to consumers, regardless of gender. In FY2016, the Health Resources and Services Administration (HRSA) will disseminate materials for education, outreach, and training to help providers better understand the importance of access to preventive services for LGBT individuals.
Updating the Blood Donation Deferral Policy
Following the completion of its research analysis, the Food and Drug Administration (FDA) issued draft guidance proposing changes to its Blood Donor Deferral Policy in May 2015. The FDA will convene a series of stakeholder listening sessions throughout the country beginning in early 2016 to hear directly from stakeholders, including the LGBT community and blood donation centers, on how an updated policy can best be implemented and how it can be improved in the future based on the most current and accurate scientific evidence available.
Meeting the Needs of People Living with HIV and AIDS
In 2015, CDC began a four-year demonstration project designed to improve outcomes for gay, bisexual, and other men who have sex with men (MSM) of color. (Up to $60 million from the Secretary’s Minority AIDS Initiative Fund will be invested in the project). Seven health departments—in jurisdictions with a high burden of HIV among Black and/or Latino MSM—will establish collaborations with community-based organizations, clinics and other health care providers, and behavioral health and social services providers to deliver comprehensive HIV prevention and care services for MSM of color.
The HHS Office of Minority Health awarded more than $2 million in grant funding to community-based organizations participating in its HIV/AIDS Initiative for Minority Men (AIMM) program. The AIMM program addresses the unmet needs of young racial and ethnic minority men who have sex with men between the ages of 20-29, young minority males living with HIV/AIDS, or those at high risk for HIV infections.
Supporting LGBT Youth
Ending Conversion Therapy by Supporting and Affirming LGBTQ Youth: In October 2015, SAMHSA published a report on positive and appropriate ways to address distress related to sexual orientation, gender identity, and gender expression with children, adolescents, and their families. This report, which was developed in collaboration with the American Psychological Association and a panel of behavioral health experts, is the first federal in-depth review of conversion therapy. As SAMHSA reported, variations in sexual orientation, gender identity, and gender expression are normal. Conversion therapy is not effective, reinforces harmful gender stereotypes, and is not an appropriate mental health treatment. Beginning this year, SAMHSA will work with partners to broadly disseminate this information to providers and other stakeholders.
Campaign to prevent and reduce youth tobacco use – The FDA has developed a public health education campaign to educate at-risk LGBT young adults about the dangers of tobacco products with the intent of preventing and reducing tobacco use among this priority population. Extensive research with LGBT young adults was conducted as part of the Agency’s rigorous campaign development process, including focus groups in seven cities across the country. The campaign is scheduled to launch in 2016, and will focus on creating a strong presence on social media platforms and at social events.
Addressing the Unique Needs of Other Populations
- Two-Spirit, American Indian, Alaska Native, and Native Hawaiian populations – The Indian Health Service (IHS) hosted a series of listening sessions on LGBT health issues in July and September 2015. IHS also instituted several training initiatives for employees this year that focused specifically on the LGBT and Two-Spirit communities. In addition, IHS funded the National Indian Health Outreach and Education II Cooperative Agreement, which was a one-year limited competition that included $100,000 for HIV/AIDS activities, explicitly inclusive of LGBT populations.
Elsewhere in the Department, ACF’s Administration for Native Americans (ANA) hosted staff training on LGBT/Two Spirit issues in the fall of 2015. In addition, ANA will conduct a session on LGBT/Two Spirit issues during its 2016 Tribal Grantee Meeting, which will focus on the services for and needs of LGBT/Two Spirit youth. These efforts complement ANA’s ongoing efforts to leverage existing technical assistance, project development, webinars, and other communications to ensure inclusiveness in all its projects.
Lastly, the Office of Intergovernmental and External Affairs will formally integrate Two-Spirit health and human services issues into the 2016 tribal consultation cycle. Tribal consultations are held each year and are designed to solicit Tribes’ priorities and needs on health and human services and programs. The sessions provide an opportunity for Tribes to articulate their comments and concerns on budgets, regulations, legislation, and policy matters. Tribal consultations are held in Washington, DC, and in each HHS Regional Office.
- Refugees, People Seeking Asylum, and Immigrants - The Department supports refugees, people seeking asylum, and those seeking to immigrate to the United States, and is LGBT-inclusive in its efforts. Representatives from ACF, and the Office of Intergovernmental and External Affairs attended events highlighting World Refugee Day (June 20). This stakeholder engagement will continue, and the Department also is exploring ways to strengthen technical assistance, and incorporate this population into ongoing Departmental LGBT initiatives and further engagements.
- Faith-based Communities – In May 2015, the Center for Faith-based and Neighborhood Partnerships (Partnership Center) hosted “Welcoming Faith Leaders,” a convening of faith leaders from across the country to discuss ways in which the faith community and health and human services agencies could partner to address LGBT health disparities. Faith leaders are often the first community partners engaged in addressing health disparities impacting historically underserved populations, including individuals who are LGBT. The Partnership Center will partner with the faith community by providing health-related information and appropriate referrals.
Advancing Data Collection and Research
HHS continues to make progress towards improving data on LGBT populations. In June 2015, ASPE convened the LGBT Data Working Group under the auspices of the HHS Data Council to assess survey questions on sexual orientation and gender identity currently used in HHS surveys, share best practices, coordinate plans, and identify approaches for making the data available for assessing the health and wellbeing of the LGBT population. Elsewhere in the Department, other work is ongoing to ensure that LGBT populations are included in HHS data collection efforts.
- ACF’s Office of Planning, Research, and Evaluation (OPRE) developed and implemented data measures for LGBT youth in foster care as part of the RISE study (Recognize Intervene Support Empower). OPRE worked with the Los Angeles LGBT Center to develop methods for accurate, sensitive, and safe identification of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth in foster care, as well as on the development of evaluation measures to assess family acceptance and cultural competency of families, caregivers, staff, and service systems. The measures were implemented via the Los Angeles Foster Youth Survey and findings are outlined in the report entitled, Sexual and Gender Minority Youth in Foster Care: Assessing Disproportionality and Disparities in Los Angeles. The report represents a first step toward population-based data collection on LGBTQ foster youth and highlights areas where further research can be conducted with LGBTQ youth in foster care.
- Administration for Community Living (ACL): ACL added questions on sexual orientation to the National Survey of Older Americans Act Participants (NSOAAP), an annual national survey of recipients of select services under the Older Americans Act (OAA). The survey obtains performance outcome information, identifies service gaps, and supports program improvements. The most recent survey in FY 2014 is the first NSOAAP to identify sexual orientation for those receiving services under the OAA.
- CDC’s National Center for Health Statistics will release a report from the second year of sexual orientation data collection on the National Health Interview Survey (NHIS). The report will include national estimates for health status, access to care and service utilization by sexual orientation using data from the 2014 NHIS.
- CDC’s Youth Risk Behavior Surveillance System (YRBS): For the first time, the 2015 national YRBS questionnaire contained two questions measuring sexual minority status – one on sexual orientation and one on sex of sexual contacts. In addition, the same two questions were added to the standard YRBS questionnaire for the first time. The standard YRBS questionnaire is used by states and cities as a starting point for their own customized YRBS questionnaires.
- CMS is testing sexual orientation and gender identity items for inclusion on the Medicare Current Beneficiary Survey.
- In September 2015, the CMS Office of Minority Health (OMH) unveiled its Equity Plan for Improving Quality in Medicare, which focuses on six priority areas and aims to reduce health disparities in four years.The Plan focuses on Medicare populations that experience disproportionately high burdens of disease, lower quality of care, and barriers accessing care.These include racial and ethnic minorities, SGMs, people with disabilities, and those living in rural areas.
- HRSA’s Bureau of Primary Health Care included SOGI questions in the 2014 Health Center Patient Survey. The public use file will be available in FY2016.
- HRSA’s HIV/AIDS Bureau revised the Ryan White HIV/AIDS Program Services Report in 2014, requiring recipients of Ryan White funding to collect new data, including clients’ sex assigned at birth. (Funding recipients were already required to collect data on clients’ gender).
- The 2014 National Health Service Corps and NURSE Corps Participant Customer Satisfaction Surveys were conducted in June and July 2015, and included a question regarding gender identity for the first time.
- The National Institute of Drug Abuse, a component of NIH, has included sexual orientation and gender identity questions on its Population Assessment of Tobacco Health Study. A longitudinal study of tobacco and health, sexual orientation and gender identity are asked of all adults as well as youth ages 14 and older.
- NIH: The Patient Reported Outcomes Measurement Information System project added targeted recruitment of additional lesbian, gay, and bisexual cancer patients and survivors through online communities to assist in the development and testing process for new chronic disease measures to ensure items are appropriate for this population
- Office of the Assistant Secretary for Health (OASH): Healthy People 2020, a national health promotion and disease prevention initiative, added two new objectives in the fall of 2014. One objective is focused on lesbian, gay, and bisexual populations, and the second objective is focused on transgender populations. These objectives track Healthy People 2020 data systems that include any data on or for LGBT populations. There are now six data systems that include validated questions on sexual orientation, and two that include validated questions on gender identity.
- SAMHSA successfully implemented sexual orientation questions in the 2015 National Survey on Drug Use and Health, and data will be publicly available in 2016. SAMHSA has also included sexual orientation in the new Common Data Platform for grantees. The Center for Behavioral Health Statistics and Quality is currently working with the Office of Management and Budget on approaches for the collection of gender identity in administrative systems.
- ACF’s OPRE published an extensive needs assessment report entitled, Human Services for Low-Income and At-Risk LGBT Populations: An Assessment of the Knowledge Base and Research Needs, which documented the human services needs of low-income and at-risk LGBT populations, and areas of future research needs. Additionally, these findings have been abbreviated and divided into briefs in three topic areas: low-income and at-risk LGBT populations, the child welfare system and LGBTQ youth and LGBT adults, and LGBTQ youth (particularly runaway and homeless youth and sexual health).
- CDC’s Office of Minority Health and Health Equity continues to provide technical assistance to the SGM Workgroup on structuring a workgroup survey and administrative process for the review of current epidemiological and intervention activities on LGBT health and to inform consideration of future studies.
- The CMS OMH launched an effort to promote health equity research to support researchers in implementing health services research activities to meet the needs of diverse CMS beneficiary populations.OMH will make available five “seats” (individual users) in its Virtual Research Data Center, which is an online platform for accessing and analyzing CMS data for research purposes.Initially, OMH is focusing on minority populations which are experiencing health care inequities due to race, ethnicity, sexual orientation, gender identity, or a disability.
- The CMS Medicare-Medicaid Coordination Office added six new condition flags to the Chronic Condition Warehouse to promote research on individuals with HIV/AIDS enrolled in Medicare and Medicaid.The new HIV/AIDS-related flags include: HIV screening; antiretroviral medication use; HIV/AIDS health care services contact; HIV/AIDS program participation; and SSA disability-qualifying primary and secondary diagnoses.
- NIH completed its strategic plan for SGM health research and released it to the public in October 2015.
- In August 2015, NIH released an administrative supplement to expand existing research to focus on SGM health.This intra-NIH effort, which involves multiple Institutes, Centers and Offices, is intended to encourage investigation in this underrepresented, yet growing field of research.The application due date is November 30, 2015.
- In the spring of 2015, the National Institute of Child Health and Human Development (NICHD), the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute co-sponsored a workshop to discuss research gaps related to the health care needs of transgender people.This meeting, jointly organized by and supported by NICHD and a conference grant to TransNet, drew together a diverse national group of experts and promising new scientists to advance the state of the science in the study of transgender health and medicine.The workshop area focused on: health disparities; gender identity development across the lifespan; clinical management of gender nonconforming children and adolescents; the safety and efficacy of transgender hormone regimens; innovative research methods; and opportunities for collaboration. A report from the workshop is being developed and several of the papers presented will be published.
- The Office on Women’s Health’s Healthy Weight in Lesbian and Bisexual Women Initiative has completed its landmark ten-city prevention trainings to achieve healthy weight in over 350 lesbian and bisexual women.The study tested a culturally sensitive 12 to 16-week curriculum focusing on healthy weight.In addition, two sites (San Francisco and Washington D.C) developed and tested a provider curriculum.The final results of this successful project (seven journal articles) were published in a supplement of the journal Women’s Health Issues in the fall of 2015.
In 2010, the Secretary of Health and Human Services established a Department-wide LGBT Issues Coordinating Committee in response to the President’s directive to identify steps the Department could take to improve the health and well-being of the LGBT community. The Committee, on behalf of the Secretary, developed the Secretary’s Recommended Actions to the President to Improve LGBT Health and Well-Being, which were sent to the President and released to the public in 2011. This fifth annual report demonstrates the Department’s commitment to these issues in the coming year and beyond. While the Department has made significant strides with regard to LGBT health and human services, HHS recognizes that there is more work to be done. The Department looks forward to the continued engagement of health experts, advocates, and community members in addition to health care providers and other partners who work hard every day to ensure that LGBT individuals have the same rights, protections, and access to quality affordable health care as all Americans.