Cross-Sectional Evaluation of State-Level Protections, Medical Debt, and Deferred Care Among Sexual and Gender Minority People

Emily Lupton Lupez; Steffie Woolhandler; David U Himmelstein; Samuel Dickman; Elizabeth Schrier; Lenore S Azaroff; Chris Cai; Danny McCormick

doi:10.1007/s11606-024-09258-9

Cross-Sectional Evaluation of State-Level Protections, Medical Debt, and Deferred Care Among Sexual and Gender Minority People

J Gen Intern Med. 2025 Jan 2. doi: 10.1007/s11606-024-09258-9. Online ahead of print.

Authors

Emily Lupton Lupez^{1

2}, Steffie Woolhandler^{3

4}, David U Himmelstein^{3

4}, Samuel Dickman⁵, Elizabeth Schrier⁶, Lenore S Azaroff⁷, Chris Cai⁸, Danny McCormick^{9

3}

Affiliations

¹ Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA. elupez1020@gmail.com.
² Harvard Medical School, Boston, MA, USA. elupez1020@gmail.com.
³ Harvard Medical School, Boston, MA, USA.
⁴ City University of New York at Hunter College, New York, NY, USA.
⁵ Planned Parenthood of Montana, Billings, MT, USA.
⁶ University of California San Francisco School of Medicine, San Francisco, CA, USA.
⁷ Edward M. Kennedy Community Health Center, Worcester, MA, USA.
⁸ Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
⁹ Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.

PMID: 39747773
DOI: 10.1007/s11606-024-09258-9

Abstract

Background: Millions of Americans have medical debt and/or defer care due to cost. Few studies have examined the association of such health-related financial problems with sexual orientation or gender identity, and whether state-level policies protecting sexual and gender minority (SGM) people affect disparities in such problems.

Objective: To examine the relationships between SGM status, state-level SGM protections, and health-related financial problems.

Design: Cross-sectional analysis.

Participants: Nationally-representative sample of U.S. adults in the 2021 National Financial Capability Study.

Main measures: Prevalence of medical debt and/or deferred care; adjusted odds ratios (aORs) by SGM status and residence in a state with fewer SGM protections.

Key results: Of 25,170 survey respondents, 3.7% were gay/bisexual men, 4.3% lesbian/bisexual women, and 0.6% transgender people. Among lesbian/bisexual women, 39.4% had medical debt, the highest proportion of any group. Accounting for sociodemographic and personal-financial factors, women and all lesbian/gay/bisexual persons (vs. straight men) more often experienced medical debt (aOR [95% CI]: straight women 1.28 [1.16, 1.41], gay/bisexual men 1.55 [1.23, 1.94], lesbian/bisexual women 1.80 [1.50, 2.10]) or deferred care (e.g., 1.80 [1.51, 2.16] for lesbian/bisexual women). Transgender people vs. cisgender men were more likely to defer care (aOR = 2.58 [1.54, 4.30]). Living in a state with fewer SGM protections was associated with higher rates of health-related financial problems for most groups, especially cisgender women and lesbian/bisexual women.

Conclusions: Lesbian/gay/bisexual, female, and transgender adults experience more health-related financial problems, especially in states lacking SGM protections, underlining the importance of universal, comprehensive insurance coverage (including for services unique to SGM people), ending bans on gender-affirming care, and closing the male-female pay gap.

Keywords: deferred care; medical debt; sexual and gender minorities.

Grants and funding

T32HP32715/HRSA/HRSA HHS/United States