*This blog was co=authored by NHeLP’s Abbi Coursolle with Angela Griffin (J.D. Candidate, May 2022, Loyola Law School, Los Angeles)
LGBTQ immigrant individuals face multiple barriers to health care access and coverage due to intersectional discrimination. As immigrants, they face discrimination when trying to access health care and are simultaneously alienated in health care settings and their own communities for identifying as LGBTQ. Research suggests that the inequities experienced by the LGBTQ immigrant community have only deepened during the COVID-19 pandemic. However, we can advocate for policy and legal changes to ensure that people receive the care and coverage they need.
Intersection of Immigration, LGBTQ, and Health Care
Many individuals and families migrate to the United States because their home countries are unsafe due to war or persecution, lack of economic opportunity, or environmental factors like natural disasters that cause displacement. LGBTQ immigrants often experience additional violence and discrimination in their home countries and are survivors of sexual violence, torture, or persecution by their families as children because of their sexual orientation or gender identity. Many LGBTQ immigrants leave their countries to escape this violence, and when they arrive in the U.S., they often experience compounded stress and trauma due to their intersectional identities as immigrants and members of the LGBTQ community.
For many immigrants, immigration status itself can create barriers to access health care. In order to receive public benefits like Medicaid, immigrants must meet federal eligibility requirements. Eligible immigrants include individuals who are Legal Permanent Residents (LPRs), asylees, or refugees. However, LPRs are subject to a five-year bar from Medicaid coverage and therefore are usually not eligible until five years after entering the United States. Furthermore, undocumented immigrants and DACA recipients are not qualified to receive full-scope Medicaid coverage.
In the U.S., an estimated 22 percent of the LGBTQ immigrant population is undocumented and approximately 4.7% of the DACA population are LGBT. Thus, many immigrants often lack access to health care through Medicaid and other public programs, leading to significantly unmet health care needs.
In addition to these discriminatory eligibility restrictions, the chilling effects of the Trump administration linger in the immigrant community. In August 2019, the Department of Homeland Security (DHS) finalized a new rule that drastically expanded the meaning of a public charge to include individuals who receive public benefits, such as Medicaid, for more than an aggregate of 12 months within any 36-month period. Generating fear and misinformation, this rule led many individuals and families to avoid or disenroll from Medicaid. During the COVID-19 pandemic, immigrant communities, already disproportionately impacted, were still avoiding public benefit programs, COVID-19 treatment, and vaccines.
These racist, xenophobic policies and attitudes toward immigrant communities wreaks havoc on their health and well-being, leading to worse health outcomes. While the Trump-era public charge rule was reversed by the Biden administration in early 2021, the rule’s chilling effect on public benefits participation and health care utilization by immigrants persists.
Many immigrants face additional discrimination and homophobia as members of the LGBTQ community. This particularly arises within their ethnic communities and families, creating a lack of connection to their community. LGBTQ immigrant individuals often do not seek health care services for fear of their immigration status being revealed or their sexual or gender identity being revealed.
These individuals often distrust government, health, and social services because of past and persistent discriminatory experiences. Additionally, a recent survey reported that LGBTQ people in the U.S. are more likely than non-LGBTQ peers to report negative experiences with their provider.
These experiences included their provider suggesting that they were to blame for a health problem, not believing they were telling the truth, or dismissing their concerns altogether. Due to this discrimination, some LGBTQ people report avoiding seeing their health care providers. Thus, many LGBTQ immigrants’ health care needs are significantly underserved.
Despite the trauma, stress, and lack of resources the LGBTQ immigrant community often experiences before and after their migration, their ability to find community and overcome these barriers is a testament to their resilience. Because of their multiple, intersecting identities, LGBTQ immigrants may not solely feel a deep connection to any one of their identities, but frequently find support systems in many different communities. Fostering an environment where LGBTQ immigrants can come together, feel a sense of belonging and feel safe to be themselves is vital to the well-being and health of this community.
Transgender Immigrant Challenges
Transgender immigrant adults face additional barriers to health care even compared to their LGBQ counterparts. Transgender people are even more likely than their LGBQ counterparts to have experienced violence and persecution in their home countries; as a result, transgender individuals disproportionately represent LGBTQ asylum-seekers in the U.S.
Unfortunately, inequities persist for transgender immigrants when they arrive in the U.S. Thirty-six percent of transgender immigrants are uninsured, twice the percentage of uninsured people in the general population. Of those insured, many individuals have issues accessing the care they need, especially transition-related health care, HIV testing and care, and medications to prevent and treat HIV. For example, in the U.S., undocumented transgender individuals are twice as likely to not know their HIV status compared to other transgender people.
Transgender immigrants also face violence because of their intersecting identities. In a national survey, data showed that undocumented transgender individuals are at a higher risk of discrimination and violence in health care and social services.
Many transgender immigrants also face physical and psychological abuse because they are not able to obtain identification documents that reflect their gender identity. For transgender immigrants in immigrant detention centers, this places them at an extremely high risk of being harassed, sexually assaulted, or placed in solitary confinement since detention centers typically house detainees based on their identification documents or their physical anatomy.
Recommendations to Meet the Health Care Needs of LGBTQ Immigrants
As COVID-19 continues to disproportionately affect Black, Indigenous, and other people of color (BIPOC), policy changes are needed to meet the needs of LGBTQ immigrants, especially those who are BIPOC, during and after the pandemic. Congress must act to pass the Health Equity and Access Under the Law (HEAL) for Immigrant Families Act. The HEAL for Immigrant Families Act seeks to remove the five-year bar to Medicaid and give DACA recipients and undocumented immigrants access to Medicaid and ACA Marketplaces.
Furthermore, more work is needed to undo the policies and rules implemented by the Trump administration. The previous administration’s attempts to weaken Section 1557, the provision of the ACA prohibiting gender identity and sexual orientation discrimination, are being reversed by the Biden Administration. However, more work must be done to ensure that Section 1557 fully protects LGBTQ people, immigrants, and limited English proficient individuals.