Sophia Keen

HONORS230

Assessment of Current State Safety-Net Hospital Environment: The LGBTQ+ Community

Today, in the United States, personal health outcomes are intrinsically tied to one’s

community. Healthcare access and the quality of health care among LGBTQ+ individuals are

sub-par both in physical and behavioral health.

Physical health encompasses diseases, conditions, and infections that affect the body. In

the LGBTQ+ community, the most notable disease that disproportionately affects them is

HIV/AIDS, specifically among gay and bisexual men. The Human Rights Campaign(HRC)

article on HIV and its effects on the LGBTQ+ population reported that “gay and bisexual men

made up an estimated 2% of the U.S. population” in 2019. Yet, in a report done by the CDC in

the same year, “gay, bisexual, and other men who reported male-to-male sexual contact

accounted for 70% (24,500) of the 34,800 estimated new HIV infections and 86% of estimated

infections among all men.” (CDC). Older individuals in the LGBTQ+ community also report

more chronic conditions and poor health as they are aging. Nearly one-third of transgender

people do not have a regular doctor and report poor general and 41% of older adults report

having a disability, compared to 35% of heterosexual older adults according to Sage, an

advocacy and services group for older LGBTQ+. Long-term care in the United States is very

(about 80%) dependent on family members, according to the Center for American

Progress(CAP). This provides a challenge for many older and aging LGBTQ+ members who

“are only half as likely as their heterosexual peers to have close relatives they can rely on for

help”. This can be attributed to the United State’s history and current stigma and treatment of

members of this community in social, professional, and personal contexts. This also provides a

unique challenge to gaining access to the United States healthcare system as “many official
policies, laws and institutional regulations prioritize only legal and biological families, and in

many instances deny resources and support to same-sex partners, families of choice and other

caregivers who do not fall into traditional categories” (CAP).

Due to discrimination and intersectional problems faced by this community, like poverty,

access and the quality of care are reported to be lesser. Overall, in the United States, LGBTQ+

individuals are more likely (22%) to live in poverty than straight cis-gendered individuals (16%).

In addition, LGBTQ+ workers reported a significantly higher job loss rate than non-LGBTQ+

workers across all working age groups(Kopparam). These correlate with the high rates of

uninsured LGBTQ+ members – a 12% rate of uninsurance compared to 7% of non-LGBTQ+

(Kopparam). It also contributes to the higher rate of delayed care among LGBTQ+ individuals.

In a study by the NHIS, LGBTQ+ individuals are more likely to have delayed care in dental,

counseling/therapy, prescriptions, and medical care. The study notes that these delays in care are

related to the fact that the LGBTQ+ population has more medical needs that are not covered by

insurance and because they face a large amount of stigma (ASPE).

Lastly, behavioral health areas that are disproportionately higher in the LGBTQ+

community include mental health, substance abuse, and addiction. Social stigma and

discrimination lower community engagement and are associated with higher rates of mental

illnesses such as depression, anxiety, and general suicidal thoughts in any population

(Weinstein). The high rate of social stigma LGBTQ+ individuals faces increases mental illness

rates. A series of statistics from Mental Health America notes the prevalence of mistreatment and

its effect on mental health. First, “A majority of LGBTQ+ people say that they or an LGBTQ+

friend or family member have been threatened or non-sexually harassed (57 percent), been

sexually harassed (51 percent), or experienced violence (51 percent) because of their sexuality or
gender identity.” and as a consequence “LGBTQ+ teens are six times more likely to experience

symptoms of depression… LGBTQ+ youth are more than twice as likely to feel suicidal and

over four times as likely to attempt suicide… Forty-eight percent of transgender adults report

that they have considered suicide in the last year, compared to 4 percent of the overall U.S.

population” (Mental Health America).

Parsing the LGBTQ+ subsets in surveys about population demographics is challenging.

The National Institute of Health released a report on accurate surveying of LGBTQ+ individuals,

identified three main challenges which lead to non-representative data: “(1) operationally

defining and measuring sexual orientation and gender identity, (2) overcoming the reluctance of

some LGBT individuals to identify themselves to researchers, and (3) obtaining high-quality

samples of relatively small populations” (NIH). This, combined with the lower prevalence of

questions regarding sexual orientation or gender identity versus other demographic metrics like

race, ethnicity, sex, or income, makes quantifying the reach that safety-net hospitals overall have

on the LGBTQ+ population difficult. Using other measures correlated with members of the

LGBTQ+ community that is more widely measured and accurate, assumptions can be made that

members of the LGBTQ+ community extensively use safety-net hospitals compared to the

general population. A characterization of Safety-net hospitals in the United States in 2014

compared the rates of different groups of patients between safety-net hospitals and non-safety-

net hospitals. Patients who fall under the lowest quartile of income in their area, mental health

hospitalizations, and uninsured patients were a higher percentage of the patient base of safety-net

hospitals, 41.2% vs. 23.9%, 7.7% vs. 4%, and 6.7% vs. 3.9% respectively(Sutton).

Safety-net hospitals address the health disparities of the LGBTQ+ community and

others by working with community programs to address social risk factors that can be
determinants of health outcomes. America’s Essential Hospitals, an association, made up of

safety-net hospitals, highlights hospitals that implement community programs. Some that directly

and indirectly impact the LGBTQ+ community include housing assistance, mental health

assistance, and community gathering and safe spaces (AEH). Safety-net hospitals also implement

their own clinics or programs in response to a concern in their specific area. In Seattle, WA a

program started in 2015 aims to “address the needs of patients with complex medical and social

needs” (Max Clinic). The Max Clinic is designed to engage with populations in King County that

are hard to reach and populations that are living with HIV. An assessment of the model of care

implemented in this clinic described the approach as “a high-intensity, low-threshold,

incentivized care model that includes walk-in access to primary care” (Dombrowski). The Max

Clinic also offers services and care such as food vouchers, cash incentives, bus passes, cell

phones for contact, and intensive case management. This innovative approach attempted to foster

an environment for patients who are not in care relating to HIV as it is traditionally and currently

implemented. HIV, as mentioned earlier in this paper, is a unique health disparity that the

LGBTQ+ community faces, especially those that identify as gay or bisexual men. In the

assessment, 8 of the 50 initial patients were heterosexual (the 42 other patients were non-

heterosexual or did not disclose the information), which shows this disproportionate reach HIV

has on the community. To quantitatively measure the program's success, viral suppression in a

year’s time was tracked by 50 Max Clinic patients and 100 similar patients that could qualify to

be treated at the Max Clinic. The results showed “Viral suppression improved in both groups

pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04)”

(Dombrowski), though the improvement in the Max Clinic was significant (P < 0.001) and much

higher compared to the control. The success of this program can be attributed to the reduced
barriers to care access by providing walk-in care and providing phones for off-clinic contact,

financial incentives, high-intensity support due to a lower medical case manager to patient ratio,

and addressing nonmedical needs such as food, transportation, and shelter. These evidence-based

approaches aim to improve care, especially for populations where traditional and/or lower-

intensity care does not work (Dombrowski).

Health reforms have also attempted to address health disparities in the LGBTQ+

community. The Affordable Care Act enacted under former President Barack Obama was the

largest of the recent health reforms that made healthcare more accessible. In the LGBTQ+

community, this proved successful as, over one year, “uninsurance among low- and middle-

income LGBT adults dropped by a quarter, from one-in-three (34 percent) uninsured in 2013 to

one-in-four (26 percent) uninsured in 2014” (Baker). In addition, LGBTQ+ adults became more

likely to report favorable interactions and care in healthcare settings. In 2016, another major

development in the Affordable Care Act led to the prohibition of “insurance companies from

denying people health insurance on the basis of a pre-existing condition like HIV and expanded

Medicaid coverage to include many low-income people living with HIV” (HRC). This, again,

lifted a barrier to health insurance and healthcare.

The Affordable Care Act led to more individuals having access to health insurance, and

thus safety-net hospitals saw an increase in patients that had insurance. This increased the money

coming into the hospitals and the patient base as well. The expansion of Medicaid eligibility led

to the most drastic changes in the patient base. The safety-net hospitals addressed in a study

reviewing the Affordable Care Act not only increased their patient base but also retained the

existing population(Felland). Most notably, the increase impacted outpatient care. The study

noted that safety-net hospitals on average had efforts to expand primary care capacity, and
improve their facilities and systems to attract or retain patients as they gained coverage. The

hospital executives reported that these changes both supported their “patients and the hospitals’

overall financial health” (Felland).

The Institute for Health Care Improvement has set a quadruple aim of goals that should

all be met in order to care for all individuals. The goals include improved health outcomes, lower

per capita cost, care team well-being, and better care experiences. Though all hospitals strive to

exceed these goals, outcomes of hospitals that care for more vulnerable populations are often

lower-performing compared to other hospitals. A major initiative that the U.S. healthcare system

implements are incentives or deductions based on reputation and performance. The reputation is

assessed by major quality rating systems which then affect the percentages of financial help

received by a hospital. Other incentives come from Medicare and Medicaid programs. According

to research done on readmission rates of hospitals and the penalizations they receive, safety-net

hospitals had higher rates of readmission for AMI, heart failure, and pneumonia, and “the

proportion of hospitals penalized during all four post-HRRP years was 72% among safety-net

and 59% among non-safety-net hospitals” (Banerjee).

Taking all of the above into consideration, the safety-net hospitals do not fully meet their

mission of caring for marginalized individuals. Much of what is preventing the safety-net

hospitals from doing their job is how the U.S. healthcare system is set up to further the funding

gap between private hospitals, which mainly see a more privileged set of patients, and safety-net

hospitals. Meeting all the criteria outlined by the Institute of Health Care Improvement and

meeting them well is especially crucial for safety-net hospitals. Their patient base, and

specifically the LGBTQ+ community, have a higher need for lower per capita costs due to

personal financial difficulties, improved health outcomes due to procedures or severe health
problems that are disproportionately centered in these populations, and improved care

experiences due to the already bad image many groups that are served in safety-net hospitals

have about healthcare and hospitals in the United States.

The current state of the safety-net hospital environment and the health of the United

States seems like a never-ending downward trend. Due to many factors, much of which stems

from a monetary perspective, for the hospitals and patients, health outcomes have not been

meeting standards of care. Despite this, there have been small advances in care that result from

innovative and creative thinking that comes from being put in tough situations. As a result, there

are a growing number of programs and approaches that safety-net hospitals are adopting that

meet their mission and serve marginalized populations.

Works Cited

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