Gaps in Health Care Access and Health Insurance Among LGBT Populations in California

Lesbian, gay, bisexual, and transgender (LGBT) adults in the United States experience many of the same challenges and barriers to accessing health care as straight and cisgender adults, including lack of insurance and poverty. However, research shows that LGBT populations are more likely to be uninsured, to be living in poverty, and to have disabilities that may impact access to health care.1 Furthermore, sexual and gender minorities have unique barriers to health care that include experiences of discrimination, lack of competent providers, and barriers to gender-affirming health care.2

Nationally, research suggests several differences in health care access by sexual orientation.3 For example, lesbian women and bisexual men and women are more likely than straight women and men to have unmet medical needs due to cost in the past year. Other research indicates that transgender adults are more likely than cisgender adults to be uninsured and to experience cost-related barriers to health care.4 Our previous research in California suggested that lesbian, gay, and bisexual women and men have similar or better rates of insurance coverage compared to straight women and men.5 Despite this, LGB women and men are more likely to experience delays in getting needed health care. Transgender adults are more likely to experience delays in getting medicine that a doctor has prescribed for them.6 

This report uses data from the California Health Interview Survey (CHIS) to examine differences in health insurance coverage and health care access by sexual orientation and gender identity. The analyses of sexual orientation differences include all gender identities (i.e., both transgender and cisgender adults), and the analyses of gender identity differences include people of all sexual orientations. Findings by sexual orientation combine data from 2017 to 2020. Combining data from these recent years allows for the presentation of findings stratified by gender, which is important because disparities vary across lesbian, gay, and bisexual people who identify as either female or male.7 Findings by gender identity use data from 2015 to 2020. Combining all the years of available data provides for more reliable estimates for this population. Measures are described in more detail under “Data Source and Methods” at the end of this report.

Gay Men and Lesbian Women More Likely To Have Employer-Based Coverage; Bisexual Men and Women More Likely To Be Insured With Medi-Cal 

In 2019–2020, 3.3% (95% CI=3.1–3.6) of California adults described their sexual orientation as lesbian, gay, or homosexual, and an additional 3.6% (95% CI=3.3–3.9) described themselves as bisexual. 

The percentage of adults with no health insurance did not vary significantly by sexual orientation (Exhibit 1). However, having employer-sponsored insurance (ESI) or Medi-Cal did. Gay men (57%) and lesbian women (54%) were more likely to have ESI than heterosexual men (48%) or women (44%). 

Bisexual men and women (31%) were more likely to have Medi-Cal coverage than other groups. The higher rates of public health insurance coverage among bisexual adults compared to monosexual adults (i.e., heterosexual, gay, or lesbian) likely reflects differences in economic stability between these subgroups. Bisexual adults in the U.S., particularly women, have among the highest rates of poverty.1,3 

Sexual Minorities, Especially Bisexual Women, Experience Barriers in Access to Health Care

Several indicators of access to care varied by sexual orientation and gender (Exhibit 2). Having a usual source of health care is important for receiving appropriate and timely care. Among women, the proportion with no usual source of care was twice as high for bisexual adults as for heterosexual adults (24% vs. 12%). Bisexual women were also more likely than heterosexual women to have had no doctor visit (18% vs. 14%) and no preventive care visit in the past year (34% vs. 23%). Differences between lesbian and straight women were not statistically significant. 

Among men, gay men had the lowest proportion with no usual source of care (13%), significantly lower than the proportions among straight men (18%) or bisexual men (27%). The same pattern is seen for having a doctor visit or a preventive care visit in the past year: Gay men were less likely to have had no doctor visit (13%) and no preventive care visit (25%) in the past year than straight men (22% and 32%, respectively) or bisexual men (25% and 40%, respectively). Differences between straight men and bisexual men were not statistically significant with regard to doctor visits or preventive care visits. Previous research in California indicated that, among men, there were no differences in having a usual source of health care across sexual orientations.8  However, unlike this current study, the earlier work did not look at differences between gay and bisexual men. This highlights the need to explore within LGB differences when studying sexual minority disparities in health care access. 

Bisexual women were more likely than straight women to experience difficulty finding a primary care provider (9% vs. 5%) and finding a specialist (20% vs. 11%). Among men, there were no statistically significant differences by sexual orientation in those who experienced difficulty finding a primary care provider or finding a specialist.

Sexual minorities were more likely to experience delays in receiving needed medical care or getting prescription medications (Exhibit 2). Among women, the proportion who experienced delays in needed medical care was higher among lesbians (23%) and bisexuals (33%) than among straight women (16%). Bisexual women (21%) were more likely than lesbians (14%) or straight women (11%) to delay getting a prescription medication. Among men, the proportions who experienced delays in getting needed medical care were higher among gay men (18%) and bisexuals (22%) than among straight men (12%). Bisexual men (16%) and gay men (12%) were more likely than straight men (8%) to delay getting a prescription medication. 

There were no statistically significant differences by sexual orientation in the percentage of people who cited the reasons for delaying care provided by the survey. However, in response to a question about whether they had been “treated unfairly” when getting medical care, sexual minorities were more likely to say that they had been (Exhibit 3). More than 40% of lesbian (44%) and bisexual (45%) women reported being treated unfairly, compared to 32% of straight women. Nearly one-third of gay men (32%) reported being treated unfairly, compared to less than one-quarter (23%) of straight men.

Transgender Adults More Likely To Have Medi-Cal Coverage, Less Likely To Have Medicare

In 2019–2020, approximately 0.8% (95% CI=0.6–1.0) of California adults were transgender. The percentages of transgender and cisgender adults with no health insurance did not differ (Exhibit 4). Transgender and cisgender adults had similar rates of insurance coverage through privately purchased plans and employer-based plans. However, transgender adults were significantly more likely than cisgender adults to be covered by Medi-Cal or other public health insurance (37% vs. 21%). Similar to bisexual adults, transgender people have higher rates of poverty.1 3 This difference in economic stability between cisgender and transgender people likely contributes to differences in rates of coverage by public health insurance. Transgender adults were also less likely to be covered by Medicare (9% vs. 20%). The difference in Medicare coverage could be explained, at least in part, by differences in age between transgender and cisgender adults, because California adults identifying as transgender tend to be younger.9

Transgender Adults Experience Several Barriers in Access to Health Care

Transgender and cisgender adults were similar in regard to having a usual source of health care and having no doctor visits in the past year (Exhibit 5). However, transgender adults were significantly more likely to have had no preventive care visit in the past year (39% vs. 28%). Transgender adults were also more likely to report having trouble finding a primary care doctor (8% vs. 4%) and finding a health care specialist (29% vs. 11%). It is possible that the much higher rate of having trouble finding health care specialists could be due, at least in part, to difficulty finding providers offering gender-affirming medical care.10

Gender minorities were more likely to experience delays in care (Exhibit 5). Transgender adults were significantly more likely than cisgender adults to delay or not get needed health care (33% vs. 14%) and to delay or not get prescribed medications (23% vs. 10%). When asked about the main reason they had delayed or gone without needed health care, cisgender adults were more likely to report that they did not have enough time or could not get an appointment. Transgender adults were more likely than cisgender adults to report transportation problems as their main reason for delaying or going without needed care (17% vs. 2%), and they were also more likely to report that their insurance was not accepted or did not cover the care (9% vs. 3%). 

When asked if they had ever been treated unfairly when getting medical care, a greater percentage of transgender respondents reported experiencing unfair treatment compared to cisgender respondents (42% vs. 28%). Although this difference is large, it was not a statistically significant difference, possibly due in part to the smaller sample size of transgender adults available in the three cycles of data collection that included this question. 

Conclusions

Sexual and gender minorities in California experience a number of barriers in access to health care, despite having similar or better rates of insurance coverage. Gay men were more likely than straight men to have experienced delays in getting needed health care and prescribed medication, even though they were less likely than straight men to have no usual source of care and to have had no preventive care visit in the past year. Bisexual men were more likely than straight men to have no usual source of care and to have experienced delays in getting needed health care and prescribed medication. Bisexual women, in particular, experienced significant barriers to accessing care relative to straight women, including being more likely to have no usual source of care, to have had no doctor visit or preventive care visit in the past year, to have had trouble finding primary care and specialty care providers, and to have delayed or not received needed health care or prescribed medication. 

Transgender adults had higher rates of Medi-Cal coverage than cisgender adults, but they were not more likely to be uninsured. Despite this, transgender adults were more likely to have experienced a number of barriers to care, including being less likely to have had preventive care visits, more likely to have had difficulty finding primary or specialty care providers, and more likely to have experienced delays in getting needed health care. 

Gay men, lesbian women, and bisexual women were more likely than straight men and women to report experiencing unfair treatment when getting medical care. A higher percentage of transgender adults than cisgender adults also reported experiencing unfair treatment when getting medical care, although this difference was not statistically significant. Other research suggests that sexual and gender minorities experience unique barriers to accessing health care. These include concerns about discrimination and negative experiences with providers, such as not being believed, being blamed for a health problem, or having their concerns dismissed.11 Taken together, these findings suggest that previous negative experiences or discrimination could contribute to some of the barriers experienced by sexual and gender minorities, including the higher rates of delayed care. 

In our previous examination of differences in access to care by sexual orientation using CHIS data from 2011 to 2014, we found that gay men were less likely than straight men to have no insurance, whereas there was no difference by sexual orientation among women.5  In addition, employer-based coverage did not vary by sexual orientation, but bisexual men and women were more likely to be covered by Medi-Cal. In contrast to the previous study, the current study found no differences in the percentages of adults without health insurance by sexual orientation among either men or women. This is likely due in part to declines in uninsured rates across all demographic groups following implementation of the Affordable Care Act (ACA) in 2013. In addition, in the current study, gay men and lesbian women were more likely than straight men and women to have ESI. This could be due in part to increases in the proportions of lesbian and gay adults who are married.12  Similar to the previous study, the current study found that bisexual men and women have higher rates of Medi-Cal coverage than straight and gay or lesbian men and women. These higher rates of Medi-Cal coverage may reflect differences in income and disability rates.13 Bisexual men and women have higher rates of poverty and disability than straight men and women. 

These findings highlight the need for clinical and structural interventions to improve health care access for sexual and gender minorities. The findings reinforce the importance of examining within LGB differences in health care access when studying sexual minority disparities, but they also suggest the need for additional research to explain existing disparities as well as similarities in access to health care. Future research should also consider within-group differences for transgender men, transgender women, and nonbinary transgender people. 

Download the full brief