Outreach and Enrollment for LGBT Individuals: Promising Practices from the Field

June 19, 2015

Tia Zeno, Katherine Warren, John Snyder

Background
People who identify as lesbian, gay, bisexual, or transgender (LGBT) have traditionally faced challenges accessing health insurance coverage and health care. On average, LGBT individuals experience greater exposure to violence and homelessness, as well as higher rates of poverty, tobacco and substance use, psychiatric disorders, HIV infection, and cancer.¹ These disparities are even more pronounced for LGBT individuals who are also members of racial and ethnic minorities and have low incomes.² According to the 2013 National Health Interview Survey, which included measures on sexual orientation, the rate of uninsurance among lesbian, gay, or bisexual adults aged 18-64 at that time was comparable to that of the heterosexual population (19.0 percent versus 20.1 percent, respectively). However, for LGBT adults with incomes below 400 percent of the Federal Poverty Level, one in three (34 percent) were uninsured in 2013, compared to 27 percent in the general population,³ and they were less likely to have employee-sponsored insurance.⁴ The percentage of LGBT adults without health insurance has decreased since the Affordable Care Act's health insurance provisions took full effect at the beginning of 2014; however, significant numbers of LGBT individuals remain uninsured.⁵

The Affordable Care Act expanded access to coverage and care for LGBT individuals and their families through the Marketplaces and Medicaid. According to the Centers for Medicare and Medicaid Services (CMS), every state operating a State-Based Marketplace (SBM) conducts outreach to local LGBT communities. In addition, all states in the Federally-Facilitated Marketplaces (FFMs) have at least two Navigator organizations, many of which work with sub-grantees and partner organizations to assist with conducting outreach to specific communities, including local LGBT individuals. A report released in July 2014 showed that the effectiveness and visibility of SBM outreach and enrollment activities in LGBT communities varied significantly based on levels of commitment to LGBT inclusion and community partnerships formed with local LGBT organizations.⁶

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) sought to understand the tailored outreach and enrollment activities in support of LGBT individuals and families within the Marketplaces. Through guided discussions with Marketplace consumer coordinators, outreach managers, and enrollment staff, we identified a set of promising practices to help enroll LGBT individuals. These findings will guide and inform efforts in the Department of Health and Human Services (HHS) to improve access to quality health care by successfully enrolling this critically underserved population in health insurance coverage.

Methods
ASPE worked with Out2Enroll⁷ to identify a diverse set of eight organizations in seven states that have been heavily involved in LGBT outreach and enrollment work under the Affordable Care Act. Three organizations were Navigator grantees or sub-grantees, while others chose to commit their own organizational resources to the outreach and enrollment effort because of its importance for connecting LGBT individuals with new affordable coverage options. ASPE staff conducted a total of eight telephone discussions, each lasting 30-45 minutes, from June to August 2014. Discussants included Marketplace consumer coordinators, outreach managers, and enrollment staff who described their outreach and enrollment practices, areas of improvement, and next steps. Table 1 shows the composition of participating organizations by location, whether the local Marketplace was an FFM or an SBM, and whether the state expanded Medicaid. Organizations included statewide health care consumer advocacy coalitions, education and law centers, not-for-profit organizations, grassroots human rights organizations, and a Federally Qualified Health Center, all striving to link residents in their states to quality, affordable health care. Appendix 1 provides more detailed information on these organizations.

Table 1. Participating Organizations

Promising Practices
Through an assessment of responses, a number of promising practices were identified. The practices described by the participants in the eight calls encompassed five major themes: outreach, partnerships, engagement, staffing, and a focus on the transgender community.

Targeted Outreach to Maximize Contact with the LGBT Community
The types of outreach and enrollment activities to LGBT individuals varied across the seven states. Groups prioritized their activities to meet the needs of the population they serve and the capabilities of their organizations, emphasizing the importance of targeted funds to support their work. Staff and volunteers conducted enrollment events and offered enrollment assistance in places where LGBT individuals gather, including community fairs, college campuses, churches and other places of worship, local social establishments, and Pride events. One organization used health fairs to reach not only fair participants, but also other vendors because booths were often staffed by people who did not have health insurance. Although some organizations used bar and club venues to reach enrollees and found this to be successful, others chose not to conduct outreach in these settings because these were not always ideal settings to have conversations about health insurance options.

Some groups reached out to constituents with targeted outreach materials via social media sites, such as Facebook and Twitter. New Voices Pittsburgh staff distributed postcards in person and asked if individuals had health insurance, if they were interested in getting health insurance, or if they knew anyone who needed health insurance. From focused community outreach, one organization collected the names of more than 2,000 uninsured people for follow-up, some of whom did not identify as LGBT. Weekly phone banking was another recruitment strategy used to reach and enroll LGBT individuals during the open enrollment period.

Strategic Partnerships to Promote LGBT Outreach
Nearly all of the organizations partnered with state and local groups to leverage support for enrollment efforts and more effectively reach the LGBT community. Many of the participating organizations worked closely with local departments of health, clinics, advisory panels, and consumer health organizations. For example, Basic Rights Oregon discussed their work with six local coalition groups: Life Long AIDS Alliance, Legal Voice, Gay Health Project, the ACLU, Gender Justice Week, and the Ingersoll Gender Center. Several organizations held town hall meetings to discuss LGBT engagement. In partnership with The Health Initiative, Georgia Equality held follow-up sessions on building a consortium of statewide organizations that could apply for Navigator funding together, focusing on inclusion of the needs of LGBT populations and the Affordable Care Act. As a result, The Health Initiative was a member of a statewide coalition of almost 20 organizations that successfully applied for and received a Navigator grant. In 2013-2014, Health Access California received an outreach grant from Covered California and used it to provide sub-grants to 11 organizations that were embedded in the LGBT community, such as clinics and community centers.

Ongoing Engagement with the LGBT Community
Sites described concerted efforts to interact with many clients as often as possible, through every step of the enrollment process. They understood the importance of creating a comfortable environment for their clients by creating space that “felt like a community center” with support groups, monthly events, and activities. Because many people, including many LGBT individuals, are unfamiliar with health insurance concepts, there were workshops on health literacy and insurance literacy. Organizations noted the importance of education on these health topics, especially given the distrust of the medical establishment felt by some members of the LGBT community due to a history of barriers to care and access, as well as perceived discrimination within the health care system.

Directed Efforts Around Staffing
Participating organizations attributed their success in part to the hiring and retention of staff with a mix of backgrounds and skill-sets. The breadth of diversity within the LGBT community led many organizations to hire from within the LGBT and/or the HIV prevention and treatment community to conduct outreach, give presentations, and serve as Navigators. Hiring LGBT individuals to work with the community ensured that staff had a greater sensitivity to LGBT concerns, used appropriate language, and had a better understanding of cultural issues. One organization hired three Navigators with experience working with transgender populations, including a transgender-identified individual. Another agency hired a transgender-rights expert because they did not have a transgender-identified Navigator.

Staffing capacity varied by site. Some organizations had Certified Application Counselors available on-site, while other sites made sure every member of their staff was trained on key provisions in the Affordable Care Act so they could answer questions and relay accurate information to enrollees. Another site held biweekly staff meetings with “everyone who touches the health plans within the whole health center” so they could stay informed and work through issues as a team.

Innovative Approaches to Engage Transgender Individuals
Organizations indicated that enrolling transgender individuals in health insurance plans can be uniquely challenging for a number of reasons. Some transgender individuals do not want to enroll because of a potential need to “out” themselves or a fear of encountering discrimination in seeking help or applying for coverage, particularly for those whose identification documents do not align with their gender identity.⁸ Others are concerned about not being able to access coverage for medically-necessary care related to gender transition. Although between 2012 and 2014, nine states plus the District of Columbia clarified that non-discrimination laws prohibit transgender exclusions in health plans, and Medicare removed its transgender exclusion in 2014, challenges remained for transgender individuals. Organizations used innovative approaches to overcome these challenges and reach this community. Several sites held informational sessions for community members and offered culturally competent, knowledgeable in-person assistance in order to create a safe and welcoming environment for transgender community members. Given the unique challenges of accessing transition-related care state-by-state, the availability of well-trained navigators was important in enrolling transgender individuals. Other groups created specific transgender initiatives to meet the unique health and legal needs of this population. One group described collaborating with their partners to offer legal services through a phone help line, and another held a Gender Justice Week for transgender clients to better understand their rights under the Affordable Care Act.

Cross-Cutting Challenges
From the guided discussions with the eight sites, two themes – data collection and materials/messaging – emerged as cross-cutting challenges.

Incorporate Data Collection to Enhance Program Evaluation
Demographic information on sexual orientation and gender identity is critical to identifying and monitoring the progress in addressing the needs of LGBT individuals. Several organizations reported that, after working hard to reach and to enroll people in health insurance plans, there were no mechanisms in place to calculate the numbers of LGBT individuals enrolled.

Moving forward, the National Health Interview Survey presents one opportunity to monitor enrollment by sexual orientation. HHS has included self-reported measures on sexual orientation and, in some cases gender identity, on nine of its national surveys.⁹ The National Survey of Family Growth has included questions on sexual orientation, attraction, and behavior for more than ten years. The Behavioral Risk Factor Surveillance System added a state module for calendar year 2014 on sexual orientation and gender identity that states could choose to adopt. The 2015 data collection of the National Survey on Drug Use and Health will include survey items on sexual orientation and sexual attraction. Inclusion of sexual orientation and gender identity data elements on national health surveys will strengthen the understanding of key LGBT health issues, including access to health care and health insurance.

Tailor Local Outreach Materials and Messaging to LGBT Community
Comparable to enrollment experiences with other hard-to-reach populations, creating simple messages for LGBT groups around a complex subject such as insurance coverage is challenging. Educational materials must also reflect how states differ in whether they have expanded Medicaid and whether they participate in a federal or state Marketplace. Organizations identified a need for more LGBT-specific materials to assist in educating enrollees about their coverage options. Some organizations asked for more technical assistance from HHS around messaging. Others noted that additional HHS materials would be valuable to explain the anti-discrimination rights of LGBT individuals and persons living with HIV. The creation of a federal health website that posts LGBT-specific materials was also suggested to further disseminate information about health disparities and why health insurance is important to LGBT individuals.

Participating organizations found social media sites, such as Facebook and Twitter, to be very useful in their outreach to LGBT groups; however, these organizations reached fewer people than groups with more resources for paid social media. Other issues raised included a need for gender-neutral language for families within the Marketplaces, the hiring of transgender staff at organizations, and more staff who speak Spanish and are familiar with LGBT issues.

Finally, organizations reported a need for more health literacy and insurance literacy workshops because many LGBT individuals are not aware of health insurance concepts and how to shop for coverage. Understanding formularies and networks are also critical because the selection of drug tiers and medical providers are locked in for a year. This is particularly important for LGBT subpopulations, such as those living with HIV and transgender individuals, who may have unique health service needs.

Moving Forward
While open enrollment periods are a critical time to reach LGBT populations, it is important for community-based organizations and Medicaid-eligible individuals to understand that this is not their only opportunity to connect to insurance. The organizations that participated in the guided discussions maintained their focus on outreach and enrollment year-round, even between the open enrollment periods. The LGBT Task Force in Health Care for All NY actively sought LGBT individuals who experienced a “qualifying life event” (e.g., marriage, giving birth, moving, or losing a job). This organization has seen many LGBT couples who have gotten married, so they worked to enroll these individuals during this qualifying enrollment opportunity. Health Access California fostered relationships with divorce attorneys as a means of increasing enrollment figures with individuals experiencing a “qualifying life event.”

For future enrollment periods, organizations said they plan to be more aggressive with their community outreach efforts. New Voices Pittsburgh continues to conduct health literacy workshops and will partner with Enroll America to implement more phone banks for the next open enrollment period. Colorado’s statewide LGBT equality organization, One Colorado, has conducted a needs assessment on the health of LGBT individuals, distributed a survey to physicians to better understand how they serve LGBT Coloradans, and worked with the Colorado Department of Health to design a behavioral risk survey on transgender health. Organizations discussed the need to stay engaged with existing local partners while creating new partnerships that bridge the gap between LGBT and consumer health advocacy.

Conclusion
The Affordable Care Act presents an unprecedented opportunity to link LGBT individuals to affordable insurance coverage. Local organizations have reached out to thousands of LGBT individuals, but many LGBT individuals remain uninsured. The widespread availability of Navigator organizations and their sub-grantees offers an opportunity to use local resources to reach LGBT individuals. During enrollment periods to come, it is important to highlight promising practices and to continue to learn from organizations that are finding success.

Appendix 1. Participating Organizations

¹ U.S. Department of Health and Human Services. Healthy People 2020: LGBT Health Topic Area (2015). Retrieved April 7, 2015 from http://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bi....² Institute of Medicine, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding (2011). Retrieved April 7, 2015 from http://www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-T....³ The Henry J. Kaiser Family Foundation (2014). Key Facts about the Uninsured Population. Retrieved May 11, 2015 from http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-popula...⁴ The Henry J. Kaiser Family Foundation (2015). Health and Access to Care and Coverage for Lesbian, Gay, Bisexual, and Transgender Individuals in the U.S. Usha Ranji, Adara Beamesderfer, Jennifer Kates, and Alina Salganicoff. Retrieved May 11, 2015 from: http://kff.org/disparities-policy/issue-brief/health-and-access-to-care-....⁵ Ibid. The change in uninsured for LGBT adults with incomes under 400 percent of the Federal Poverty Level declined from 34 percent in 2013 to 25 percent in 2014. During the first open enrollment period under the Affordable Care Act, the rate of uninsurance among LGBT individuals fell 24 percent.⁶ Out2Enroll. Key Lessons for LGBT Outreach and Enrollment: Under the Affordable Care Act. (2014). http://out2enroll.org/key-lessons-for-lgbt-outreach-enrollment/⁷ Out2Enroll is a collaborative initiative between the Center for American Progress, the Sellers Dorsey Foundation, and the Federal Agencies Project. HHS partners with Out2Enroll to encourage LGBT individuals to obtain coverage.⁸ Transgender individuals may have questions about which sex (male or female) they should select as part of the application process, particularly since many transgender individuals encounter financial and other barriers to changing identification documents, such as a driver’s license or birth certificate, to accurately reflect their gender identity.⁹ The nine federal surveys and the HHS operating divisions that collect information on sexual orientation include: Health Center Patient Survey (HRSA); National Health Interview Survey (CDC/NCHS); Youth Risk Behavior Surveillance System (CDC); National Adult Tobacco Survey (CDC); National Health and Nutrition Examination Survey (CDC/NCHS); National Survey of Family Growth (CDC/NCHS); Population Assessment of Tobacco Health (NIH/NIDA); National Survey on Drug Use and Health (SAMHSA); Behavioral Risk Factor Surveillance System (CDC).