Health Care on the Line: The ACA helped LGBT Americans heal in more ways than one

Editors’ Note: As the case against Affordable Care Act goes before the U.S. Supreme Court this week, the Center for Health Journalism is sharing a series of stories about the impacts of this transformative law.

As I grew up, I felt that Washington, D.C. was worlds removed from my tiny Appalachian hometown. Then, the Affordable Care Act (ACA) saved my life.  Now the Supreme Court is considering whether to dismantle or uphold the law. LGBT people like me hang in the balance.

I had always imagined that I would first come out at my family’s table, chewing on my fingernails instead of a dinner roll. Instead, I first disclosed my sexuality to my doctor, in 2016. I was waiting for my medical appointment, halfheartedly ticking off the general demographic information until I saw “lesbian” and “bisexual” listed on the doctor’s paperwork. I froze, holding my pen.

Part of me wondered if the question was a trap. After all, the National Center for Transgender Equality had interviewed patients before the ACA was enacted: 19% of LGBT people reported that doctors had refused to treat them because of their sexuality or gender identity, and 28% said they avoided going to the doctor or hospital because they feared discrimination. These issues and fears were all too familiar to millions of LGBT people. Many of us assured our doctors, “No, I’m not sexually active,” before we returned home to our same-sex partners.

But on that day in 2016, with a deep breath and a silent checkmark, I came out. I was almost 20 years old.

Coming out to a doctor isn’t just a matter of pride. A doctor-patient relationship relies on trust, and LGBT folks can’t receive the care they need when they don’t feel safe to come out to their providers. Until 2016, insurance companies could legally classify gender dysphoria as a pre-existing condition. Likewise, health care practitioners around the country could turn away LGBT patients in need.

People in Appalachia have some of the highest rates of pre-existing medical conditions in the country. When I was a child, my grandmother pulled out her rotten teeth with a pair of pliers from her toolbox to save money. She explained, “Why would I pay a dentist hundreds of dollars when I can do it myself?”

Many queer Appalachians cope with heart disease, cancer and other conditions. It’s a cruel irony that health care providers falsely pathologized non-conforming gender and sexual identities while refusing to treat the very real illnesses that kill us. Nearly a quarter of LGBT people, myself included, have gone without health insurance. I received my care in a clinic run by the local health department. If that clinic turned me away, I had nowhere else to go.

I hadn’t disclosed my sexuality on previous doctor’s visits. Was I lying by omission to the doctor who checked my suspicious mole when I was a teenager? Or was I just trying to save my own skin?

The ACA helped LGBT Americans heal in more ways than one. This policy galvanized our medical system, and the queer community, because it provided the nation’s first LGBT health protections. Before I came out to my doctor, the Obama administration refined Section 1557, which prohibits health care facilities that receive federal funding from turning someone away based on gender identity or sexual orientation. These anti-discrimination rules have protected countless LGBT patients, even those already enrolled in a private health plan.

My doctor told me that Section 1557 had inspired him to add more questions about identity to his intake forms. It made me feel more comfortable going to the doctor.  I did not know the protections would save my life.

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The ACA made it possible for me to be open with my doctor without fear of retribution, so I began asking about reproductive care and mental wellness. A year later, I went back to the doctor because I had lost weight and was feeling down. For months, I had fantasized about not being alive anymore. I’d started giving away my possessions. And after a lifetime of fearing the dark, imagining monsters and ghouls in the shadows, I no longer felt afraid at night — not because the demons were gone but because I already felt like I was in hell. 

I didn’t have the language to describe the exhaustion in my mind and soul. I did not understand these thoughts were suicidal, because I hadn’t planned, step-by-step, how I would die. Fortunately, my doctor recognized the danger. I’m alive today because he immediately connected me with affordable mental health care.

LGBT people ages 10-24 are five times more likely to attempt suicide than their cisgender and heterosexual peers. Because I had disclosed my sexuality to my doctor, he knew I was at a higher risk. I wonder how many young queer and transgender people have died because they kept their pain to themselves.

From 2013 to 2016, the Affordable Care Act reduced LGBT uninsurance rates by 35%. ACA policies are one reason why a person diagnosed with HIV/AIDS in 2018 had a 10-year longer life expectancy than someone diagnosed in 2010. While more effective treatments and other scientific advances have changed HIV/AIDS from a highly lethal disease into a manageable one, nobody should underestimate how the ACA transformed HIV/AIDS care with vital preventative measures such as free screenings. Additionally, the ACA funds training with the National Health Service Corps to teach doctors how to best serve patients with HIV/AIDS. 

Equally important as the health care gains for LGBT people, we have hope. Many are alive because they have health care. Healthier people may live more fulfilling lives, have the energy to volunteer more in their communities, or even join the unprecedented number of LGBT candidates running for office.

Still, inequities linger. Queer and trans people are twice as likely to be uninsured than their heterosexual and cisgender peers. If the Supreme Court upholds the ACA, Congress will have an opportunity to fix the law’s shortcomings, close the gaps in coverage, and make sure that all of us, no matter our identity, have access to the care we deserve. A country is only as healthy as its people.