Key Findings

There has been rising attention to the scope of mental health challenges in the United States, including a desire to better understand the experiences and needs of those who may be most heavily impacted. The LGBT+ community is one such group, having faced lifelong mental health challenges beginning in adolescence and persisting through adulthood. While in some cases, LGBT+ people are accessing mental health care more frequently than non-LGBT+ people, their need for services is greater, and gaps remain. Today, policies seeking to curtail access and rights of LGBT+ people threaten to worsen these disparities, and continuing to monitor the wellbeing of the community will be important.

With this report, we examine LGBT+ people’s needs for and experiences accessing mental health care by analyzing data from a nationally representative 2022 KFF survey with a large sample of LGBT+ adults. Key findings include:

• Two-thirds of LGBT+ people (67%) reported needing a mental health service over the past two years, a considerably higher share than for non-LGBT+ people (39%).
• Yet, only about half of LGBT+ people with a reported need sought and received mental health services (similar to the share among non-LGBT+ people).
• Barriers to care can include:
  • Wait times: Four-in-ten LGBT+ people reported having to wait at least a month for services.
  • Insurance: One-quarter of privately insured LGBT+ people who received mental health services said their provider did not take their insurance.

Introduction

There has been rising attention to the depth and breadth of mental health challenges in the United States, including a desire to better understand the experiences and needs of those most heavily impacted. A recent KFF/CNN poll found that nearly all (90%) Americans believe there is a mental health crisis today and that LGBT+ adults consistently reported poorer mental health outcomes on almost all measures throughout the survey.

Indeed, the LGBT+ community has faced lifelong mental health challenges beginning in adolescence and persisting through adulthood at higher rates compared to non-LGBT+ people. Additionally, while in some cases, LGBT+ people are accessing mental health care more frequently than non-LGBT+ people, their need for services is greater and gaps remain. Addressing systemic factors that drive stigma and discrimination within the community could play a key role in mitigating these challenges alongside improving access more generally.

With this report, we provide an update on LGBT+ people’s needs for and experiences of accessing mental health care by analyzing data from a nationally-representative 2022 KFF survey of 6,442 adults ages 18 to 64, including 958 LGBT+ people, conducted primarily online from May 10, 2022, to June 7, 2022. For this survey, LGBT+ people include those who identified their sexual orientation as lesbian, gay, bisexual, or “something else,” and those who identified their gender as transgender, non-binary, “other,” or whose reported gender does not correspond to their reported sex assigned at birth. (See the Methodology for additional detail.) Beyond issues related to mental health and access to care, the survey collected data on a range of demographic characteristics and issues from general well-being to experiences engaging in the health system, use of preventive services including HIV and STI testing, and reproductive health. A separate companion issue brief, LGBT+ People’s Health Status and Experiences Accessing to Care, provides these additional findings.

Findings

Experiences with Mental Health Problems

Surveys regularly find that LGBT+ people face greater mental health challenges than non-LGBT+ people, including for common conditions like depression and anxiety, as found in a recent KFF/CNN poll.

Here we find that two-thirds of LGBT+ people (67%) reported needing a mental health service over the past two years, a considerably higher share than the one-in-four non-LGBT+ people (39%). Self-reported need for mental health care was highest among younger LGBT+ people under age 35 (77%) and for women, nearly three-quarters of whom (73%) reported the need for mental health care (Figure 1).

Accessing Mental Health Care

The higher rates of stigma, discrimination, and violence experienced by LGBT+ populations can translate into mental health and substance use challenges. For many who are part of this community, these challenges highlight the need for behavioral health care.

While reported need for mental health services was high among LGBT+ people, not all of those with a need for services sought or received them. Notably, a higher share of LGBT+ people have both a need for mental health service than non-LGBT+ people, and higher shares sought and received mental health services than their non-LGBT+ counterparts. Yet, unmet need persisted for many in both groups.

Two-thirds (65%) of LGBT+ people who reported needing a mental health service sought one, compared to 58% of non-LGBT+ people, still leaving many without desired services (Figure 2). There were no statistical differences in the share that sought services by age, race/ethnicity, or insurance status among LGBT+ people. Limited uptake could be due to being a lower-income group, having lower rates of private coverage, or experience of stigma, discrimination shame and trauma, including within medical settings. See the issue brief LGBT+ People’s Health Status and Experiences Accessing to Care for more details.

Only about half of LGBT+ people (55%) and non-LGBT+ people (49%) who reported a need for mental health services over the past two years received care, pointing to substantial unmet need in this area regardless of gender identity or sexual orientation. One-in-ten (10%) LGBT+ who reported a need for these services said they tried to get but did not receive care, also similar to non-LGBT+ people. One-third (35%) with a need did not try to get mental health care (Figure 3). A smaller share of LGBT+ individuals with a need did not try to get mental health care compared to non-LGBT+ individuals (35% vs. 42%).

Since the COVID-19 pandemic, telehealth has emerged as an important avenue for people to access health care, including mental health services. Almost two-thirds of LGBT+ people (63%) reported having had a telehealth visit in the last year and mental health services was the leading reason for their most recent telehealth visit – 28% received mental health services, followed by an annual check-up or well-visit (21%). Telehealth can increase access to mental health services, including for those who might not otherwise get or want in-person care (data not shown in figure).

Barriers to Mental Health Care

Among LGBT+ people who were able to get a mental health appointment, about six-in-ten (58%) were able to get one in less than a month, but four-in-ten (42%) had to wait one month or more, with 16% waiting more than two months. These were similar to the shares among non-LGBT+ people. Such delays can be a barrier to getting people into care, particularly when those who have to wait may end up not seeking care at all if that wait is for a substantial period. These delays can prolong suffering and lead to worsening of symptoms (Figure 4).

Seven-in-ten (69%) privately insured LGBT+ people reported their mental health provider accepted their insurance plan, but 27% said they did not, and 4% didn’t know, shares similar to privately insured non-LGBT+ people (Figure 5).

Conclusion

LGBT+ people experience significantly higher rates of mental health challenges and need for mental health services than non-LGBT+ people, as well as higher rates of health care discrimination. While they also reported accessing mental health care at slightly higher rates than non-LGBT+ people, nearly half who said they could benefit from such services went without. The findings presented here suggest that in addition to inability to secure appointments, wait times may also be a barrier to care. A facilitator to mental health care appears to be telehealth, with more than one-quarter of LGBT+ people accessing telehealth care doing so for mental health services.

The reasons that LGBT+ people are more likely to face mental health challenges are complex and may relate, in part, to widespread experiences of stigma and discrimination. Current attempts to institute anti-LGBTQ policies in many states and communities may contribute to poor mental health outcomes and increase the need for care. Targeted and culturally appropriate policy solutions aimed at improving the well-being of the LGBT+ community and addressing their access challenges to mental health care could help to meet their mental health care needs, as would efforts to address systemic factors that drive stigma and discrimination within the community.

Methods

Data for this issue brief come from the 2022 KFF Women’s Health Survey, a nationally representative survey of 6,442 people of all genders ages 18 to 64, including 958 LGBT+ people, conducted from May 10, 2022, to June 7, 2022. The objective of the survey is to help better understand respondents’ experiences with contraception, potential barriers to health care access, and other issues related to reproductive health. The survey was designed and analyzed by researchers at KFF (Kaiser Family Foundation) and fielded online and by telephone by SSRS using its Opinion Panel, supplemented with sample from IPSOS’s KnowledgePanel.

The survey asked respondents which sex they were assigned at birth, on their original birth certificate (male or female). They were then asked what their current gender is (man, woman, transgender, non-binary, or other). Those who identified as transgender men are coded as men and transgender women are coded as women. While we attempted to be as inclusive as possible and recognize the importance of better understanding the health of non-cisgendered people, as is common in many nationally representative surveys, we did not have a sufficient sample size (n >= 100) to report gender breakouts other than men and women with confidence that they reflect the larger non-cisgender population as a whole. The data in our reproductive health analyses use the respondent’s sex assigned at birth (inclusive of all genders) to account for reproductive health needs/capacity (e.g., ever been pregnant) while other analyses use the respondent’s gender (inclusive of males and females).

For this survey, LGBT+ people include those who identified their sexual orientation as lesbian, gay, bisexual, or “something else,” and those who identified their gender as transgender, non-binary, “other,” or whose reported gender does not correspond to their reported sex assigned at birth.

Questionnaire design

KFF developed the survey instrument with SSRS feedback regarding question wording, order, clarity, and other issues pertaining to questionnaire quality. The survey was conducted in English and Spanish. The survey instrument is available upon request.

Sample design

The majority of respondents completed the survey using the SSRS Opinion Panel (n=5,202), a nationally representative probability-based panel where panel members are recruited in one of two ways: (1) through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Group through the U.S. Postal Service’s Computerized Delivery Sequence. (2) from a dual-framed random digit dial (RDD) sample provided by Marketing Systems Group.

In order to have large enough sample sizes for certain subgroups (females ages 18 to 35, particularly females in the following subgroups: lesbian/gay/bisexual; Asian; Black; Hispanic; Medicaid enrollees; low-income; and rural), an additional 1,240 surveys were conducted using the IPSOS KnowledgePanel, a nationally representative probability-based panel recruited using a stratified ABS design. (Note that due to small sample sizes, data for LGBT+ people who are Asian or Pacific Islanders are not presented in this report.)

Data collection

The majority of surveys completed using the SSRS Opinion Panel (n=5,056) and all of the surveys completed using the KnowledgePanel (n=1,240) were self-administered web surveys. Panelists were emailed an invitation, which included a unique passcode-embedded link, to complete the survey online. In appreciation for their participation, panelists received a modest incentive in the form of a $5 or $10 electronic gift card. In addition to the self-administered web survey, n=146 surveys were completed by telephone with SSRS Opinion Panelists who are web reluctant.

Weighting

The data are weighted to represent U.S. adults ages 18 to 64. The data include oversamples of females ages 18 to 35 and females ages 36 to 64. Due to this oversampling, the data were classified into three subgroups: females 18 to 35, females 36 to 64, and males 18 to 64. The weighting consisted of two stages: 1) application of base weights and 2) calibration to population parameters. Each subgroup was calibrated separately, then the groups were put into their proper proportions relative to their size in the population.

Calibration to Population Benchmarks

The total sample for the Women’s Health Survey was balanced to match estimates of each of the three subgroups (females ages 18 to 35, females ages 36 to 64, and males ages 18 to 64) along the following dimensions: age; education (less than a high school graduate, high school graduate, some college, four-year college or more); region (Northeast, Midwest, South, West); and race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic-born in U.S., Hispanic-born Outside the U.S., Asian non-Hispanic, Other non-Hispanic). The sample was weighted within race (White, non-Hispanic; Black, non-Hispanic; Hispanic; and Asian) to match population estimates. Benchmark distributions were derived from 2021 Current Population Survey (CPS) data. Although the LGBT+ sample in this survey is not weighted separately to match population benchmarks, the full sample is. Comparisons to the available demographic data for the LGBT population from the 2021 Behavioral Risk Factor Surveillance System (BRFSS) found the demographics from our sample closely align with the federal data source.

Margin of Sampling Error

The margin of sampling error, including the design effect for subgroups, is presented in Table 1 below. It is important to remember that the sampling fluctuations captured in the margin of error are only one possible source of error in a survey estimate and there may be other unmeasured error in this or any other survey.

The KFF Women’s Health Survey sample includes people of all genders; however, our sample design is more heavily focused on women. While our survey weights take this gender imbalance into account and we use additional data control measures to ensure the data we present are as reliable and as representative of the population as possible, some data points for certain subgroups with larger margins of error may be more heavily weighted by women than men. Caution should be exercised in interpreting findings among LGBT+ subpopulations due to smaller sample sizes and larger margins of error. Our issue briefs do not present data for subgroups where data limitations precluded us from developing reliable estimates.

STATISTICAL SIGNIFICANCE

All statistical tests are performed at the .05 confidence level. Statistical tests for a given subgroup are tested against the reference group (Ref.) unless otherwise indicated. For example, White is the standard reference for race/ethnicity comparisons and private insurance is the standard reference for types of insurance coverage. Some breakouts by subsets have a large standard error, meaning that sometimes even large differences between estimates are not statistically different.

See the full 2022 KFF Women’s Health Survey methodology for more details. The full survey instrument is available upon request.

Key Findings

The share of people in the United States who identify as LGBT+ has increased substantially in recent years, yet health disparities and health access-related challenges persist across multiple dimensions. While in some areas, the health experiences of LGBT+ people mirror those of their non-LGBT+ counterparts, studies have found that this population experiences certain challenges at higher rates. Understanding the health care needs and experiences of LGBT+ people, and where they differ from those who are not LGBT+, is therefore important for addressing barriers and facilitating access to care and coverage. This report, based on a nationally representative 2022 KFF survey, provides an analysis of the health experiences of self-identified LGBT+ adults in the U.S. compared to their non-LGBT+ counterparts. Key findings include:

Demographics, Coverage and Health Status

• The demographics of the LGBT+ adult population were similar to non-LGBT+ adults with respect to gender, race/ethnicity, urbanicity, and working status, but a significantly greater share were younger.¹ 
• Despite being a younger population, LGBT+ individuals were more likely to report being in fair or poor health and were managing chronic conditions and living with disabilities at higher rates than non-LGBT+ people.
• LGBT+ people were less likely be privately insured and more likely to have Medicaid coverage than their non-LGBT+ counterparts, with similar shares uninsured.

Access to and Use of Care

• LGBT+ people reported lower rates of having a usual source of care than their non-LGBT+ counterparts but reported wider use of telehealth visits.
• The large majority of LGBT+ people saw a health care provider in the past two years, but a smaller share had a recent check-up or well-woman visit. The share in both cases is similar to those among non-LGBT+ people. Those who were uninsured were less likely than those with coverage to have seen a provider or had a check-up.
• Uptake of health services differs by LGBT+ status in some cases. For example, LGBT+ people reported higher testing rates for sexually transmitted infections (STIs) and HIV, but lower uptake of pap smears. In addition, larger shares of LGBT+ people reported regularly taking prescription medications than non-LGBT+ people, despite being a younger population overall.
• LGBT+ people reported needing mental health services over the past two years at much higher rates than non-LGBT+ people. Moreover, not all those who said they needed mental health services received them.
• LGBT+ people, like non-LGBT+ people, commonly reported problems with health care costs impacting their ability to pay for basic necessities such as food, heat, and housing, among other challenges.
• The majority of LGBT+ people assigned female at birth have used contraception at some point in their lifetime (70%) and over half do so for a reason other than preventing pregnancy. They were less likely than non-LGBT+ people to say they have ever been pregnant (40% compared to 70%).

Provider Interactions

• LGBT+ people reported higher rates of discrimination during a health care visit compared to non-LGBT+ people.
• LGBT+ people were also more likely to report a range of recent negative provider experiences, including having had a provider who did not believe they were telling the truth or suggested they were to blame for a health problem, among others. These experiences were most common among LGBT+ people who were women, younger, had low incomes, and/or reported a disability or chronic disease.

 

Background

The share of people in the United States who identifies as LGBT+ has increased substantially in recent years, particularly among younger generations, yet health disparities and health access-related challenges persist across multiple dimensions. Understanding the health care needs and experiences of the more than 7% of LGBT+-identified people in the United States, including the one-in-five younger adults from Generation Z, is important for addressing barriers and facilitating access to care and coverage.

While in some areas, the health experiences of LGBT+ people mirror those of their non-LGBT+ counterparts, studies have found that this population experiences certain challenges at higher rates than those who identify as heterosexual and cisgender, challenges which intersect with factors beyond sexual orientation and gender identity to include race/ethnicity, class, nationality, and age, among other aspects of identity. Recognizing this, the National Institutes of Health (NIH) identified sexual and gender minorities as a “health disparity population” to encourage and support research in this area. Further, the Biden administration has taken multiple steps to address equity in the LGBTQ community, including with respect to data collection and health care, including issuing multiple executive orders in this area, announcing that the HHS Office for Civil Rights (OCR) would include gender identity and sexual orientation as it interprets and enforces the ACA’s prohibition against sex discrimination (Section 1557), opposing state actions aimed at limiting access to gender-affirming care for transgender and gender non-conforming people, adopting protections for LGBTQ+ youth and working to provide protections for health care workers delivering gender affirming care, and issuing a Federal Evidence Agenda on LGBTQI+ Equity, a “roadmap for federal agencies” regarding “data-driven and measurable [sexual orientation and gender identity] SOGI Data.”

Despite progress in researching these issues over the past decade and increased federal commitment, much population-based research still does not include measures of sexual orientation and gender identity, limiting the ability of policymakers, policy implementers, and researchers to assess national trends and disparities, and identify needed interventions. With this report, we add to the knowledge base in this area by analyzing nationally representative data from a 2022 KFF survey of 6,442 adults ages 18 to 64, including 958 LGBT+ people, conducted primarily online from May 10, 2022, to June 7, 2022. For this survey, LGBT+ people include those who identified their sexual orientation as lesbian, gay, bisexual, or “something else,” and those who identified their gender as transgender, non-binary, “other,” or whose reported gender does not correspond to their reported sex assigned at birth. See the Methodology for additional detail.

The survey collected data on a range of demographic characteristics and issues from general well-being to experiences engaging in the health system, use of preventive services including HIV and STI testing, reproductive health, and mental health. (See also our issue brief Mental Health Care Needs and Experiences Among LGBT+ People).

Demographics

The demographics of LGBT+ adults generally mirror those of non-LGBT+ adults in many ways, with age and income being notable exceptions (Figure 1).

• LGBT+ adult demographics look similar to non-LGBT+ adults with respect to gender, race/ethnicity, urbanicity, and working status.
• Yet LGBT+ adults are significantly younger, with almost two-thirds (62%) between the ages of 18 and 35 compared to 36% of non-LGBT+ adults.
• LGBT+ people are also more likely than non-LGBT+ people to have lower incomes, with 44% of LGBT+ people earning less than 200% of the federal poverty level ($13,590 per year in 2022 for an individual) compared to 36% of non-LGBT+ people.

Health Status

LGBT+ people were more likely to be in fair or poor health than non-LGBT+ people despite being a younger population overall (Figure 2).

• One-quarter (25%) of LGBT+ people reported being in fair or poor health compared to 18% of non-LGBT+ people. This was especially common among LGBT+ people with low incomes²  and those covered by Medicaid.
• There were no statistically significant differences by race/ethnicity or gender.

LGBT+ people were managing chronic conditions and living with disabilities that impact daily life at higher rates than non-LGBT+ people (Table 1).

• Half (50%) of LGBT+ people reported that they had an ongoing health condition that requires regular monitoring, medical care, or medication, a higher share than non-LGBT+ people (45%).
• Additionally, a larger share of LGBT+ people reported having a disability or chronic disease that keeps them from participating fully in work, school, housework, or other activities than non-LGBT+ people (25% v. 16%). There were also notable differences within the LGBT+ community.
  • LGBT+ adults between the ages of 45-64 reported markedly higher rates of ongoing conditions requiring care or medication than younger LGBT+ adults ages 18-44 (44% v. 70%).
  • A larger share of LGBT+ people ages 18-44 reported having a disability or chronic disease (26%) than non-LGBT+ people in this age range (12%) (data not shown in table).
  • LGBT+ people with Medicaid faced especially high rates of disability, which is one of the eligibility pathways into the program, compared to LGBT+ people with private insurance coverage (45% v. 15%).

Insurance Coverage and Access to Care

A smaller share of LGBT+ people had private insurance (59%) and more had Medicaid coverage (21%) than their non-LGBT+ counterparts (64% and 16%, respectively), reflecting their lower incomes which were driven, at least in part, by being a younger population (Figure 3). Similar shares were uninsured.

Most LGBT+ people reported having a regular doctor or health care provider, though they were less likely to have one than non-LGBT+ people.

• LGBT+ people reported lower rates of having a regular doctor or provider than their non-LGBT+ counterparts (72% v. 77%) (Figure 4). Research has found that having a usual source of care is associated with increased use of preventive care and better health outcomes.
• Among LGBT+ people, rates were significantly lower for those ages 18-44 than those ages 45-64 (68% v. 86%) and among those who were uninsured (36%).

Nearly three-quarters (74%) of LGBT+ people with a usual source of care got that care at a doctor’s office, though one in five (20%) obtained their routine care at a clinic, such as a health department, health center, school clinic, urgent care center, or clinic inside a store or pharmacy. Smaller shares went to an emergency room or some other place (6%) (Figure 5). The type of location where care was received was similar among LGBT+ and non-LGBT+ people (data not shown in figure).

Telehealth has become an increasingly common way to access care, including among LGBT+ people, who reported higher use of telehealth visits over the past two years than did non-LGBT+ people (63% v. 53%) (Figure 6).

• There were no statistically significant demographic differences among LGBT+ people who used telehealth in the past two years except for those who were uninsured, who reported lower rates of telehealth use (39%) than those with Medicaid (67%) or private insurance (64%). Similarly, non-LGBT+ people without insurance reported lower rates of telehealth use than those with Medicaid and private insurance (data not shown in figure).
• About one in ten (9%) LGBT+ people reported using an online prescribing platform or app, such as Nurx, The Pill Club, Roman, or hims/hers to receive a prescription or health care service, similar to the share among non-LGBT+ people (6%) (data not shown in figure).

Use of Health Care Services

More than nine in ten (93%) LGBT+ people saw a doctor or health care provider in the past two years but fewer than three-quarters (73%) of this group had a general check-up or well-woman visit³  in that period. Both findings were similar to the share among non-LGBT+ people (Table 2).

• LGBT+ people who were uninsured were significantly less likely than those with health coverage (either Medicaid or private insurance) to have seen a provider (80% v. 94%) or had a wellness check-up in the past two years (57% v. 74%).

Use of preventive cancer screenings can lead to early identification of conditions when they are more responsive to medical interventions and potentially avert serious complications. While uptake of colonoscopies among LGBT+ people was similar to that of non-LGBT+, slightly higher shares of non-LGBT+ people reported having had a pap smear in the past two years than LGBT+ people (Figure 7).

• Slightly smaller shares of LGBT+ people assigned female at birth⁴  ages 21-64 reported having had a pap smear in the past two years than their non-LGBT+ counterparts (54% v. 59%).
• Forty-five percent of LGBT+ people ages 45-64 reported having had a colon cancer screening in the past two years, similar to non-LGBT+ people (37%).

A higher share of LGBT+ people reported taking at least one prescription medication on a regular basis than non-LGBT+ people, despite being a younger population overall (62% v. 55%) (Figure 8).

• As with non-LGBT+ people, prescription use among LGBT+ people increased with age.
  • However, the share of LGBT+ taking a prescription was higher across each age group, except those ages 45 to 64, when compared to non-LGBT+ people.
• Looking at the youngest group, more than half (54%) of LGBT+ people ages 18 to 24 reported regularly taking a prescription compared to just over one-third (36%) of non-LGBT+ people in the same age group.

Sexual and Reproductive Health

LGBT+ people reported higher rates of receiving testing for sexually transmitted infections (STIs) and for HIV than their non-LGBT+ counterparts, services that are recommended for early detection, treatment, and preventing transmission (Table 3).

• However, uptake is still relatively low. Thirty-five percent (35%) of LGBT+ people ages 18-64 have been tested for HIV in the past two years, higher than the share of non-LGBT+ people (19%).
  • Among LGBT+ people, testing rates were highest among those ages18-44.
• Nearly four in ten (37%) LGBT+ people ages 18-64 have been tested for an STI (other than HIV) such as chlamydia or herpes in the past two years, higher than the share of non-LGBT+ people (19%).
  • Among LGTB+ people, STI testing rates were also higher among those who were younger (43%).

The majority (70%) of LGBT+ people assigned female at birth⁵  have used contraception in their lifetime, compared to 77% of their non-LGBT+ counterparts, and most used more than one type of contraception across their lifetime (70%). Three in four (75%) sexually active reproductive-age (18-49) LGBT+ people assigned female at birth who were not pregnant reported using contraception in the past year. The share of LGBT+ people using contraceptives is largely driven by bisexual women.

• Over half (55%) of LGBT+ reproductive-age people assigned female at birth who used contraception in the past year did so for a reason other than preventing pregnancy compared to 35% of their non-LGBT+ counterparts. This share includes the nearly one in five (18%) LGBT+ people who used contraception solely for a reason other than preventing pregnancy, like managing a medical condition or preventing an STI (Figure 9).

The share of LGBT+ reproductive-age people assigned female at birth had similar contraceptive method use patterns to non-LGBT+ females (Table 4).

• However, larger shares of LGBT+ people said they used injectable contraception, contraceptive patches, contraceptive implants, and male condoms compared to non-LGBT+ females.

Across the lifespan, four in ten LGBT+ people ages 18-64 assigned female at birth have ever been pregnant compared to seven in ten non-LGBT+ females (Figure 10).

• Lower shares of LGBT+ people said their pregnancies resulted in a birth, while higher shares said they have experienced a miscarriage compared to their non-LGBT+ counterparts.

Mental Health

Two-thirds (67%) of LGBT+ people reported needing a mental health service over the past two years, compared to four in ten (39%) non-LGBT+ people (Figure 11). Surveys regularly find that LGBT+ people are more likely than non-LGBT+ people to experience mental health conditions such as depression and anxiety, which can result from ongoing experiences of discrimination, stigma, and violence.

• Among LGBT+ people, self-reported need for mental health care was higher for those who were younger (ages 18-34) compared to those ages 35-64 and for those with Medicaid compared to those with private insurance (data not shown in figure but available in Mental Health Care Needs and Experiences Among LGBT+ People).

While the reported need for mental health services was high among LGBT+ people, not all of those with a need for services sought or received them.

• Sixty-five percent (65%) of LGBT+ people who reported needing a mental health service sought one, a higher share than among non-LGBT+ people (58%), but more than one-third (35%) did not (Figure 12).

For additional detail on mental health and LGBT+ people see our companion issue brief on this topic, Mental Health Care Needs and Experiences Among LGBT+ People.

Provider Interactions

LGBT+ people were more likely to report a range of negative provider experiences in the past two years compared to non-LGBT+ people. This may limit their willingness to seek care, which could be especially problematic for this group which has higher rates of certain health conditions compared to non-LGBT+ people. Negative interactions included having a provider not believe they were telling the truth, suggesting they were personally to blame for a health problem, assuming something about them without asking, or dismissing their concerns. LGBT+ people were more likely to report experiencing discrimination based on their age, gender, race, sexual orientation, religion, or some other personal characteristic during a health care visit (Figure 13).

• Altogether, nearly half (45%) of LGBT+ people who had visited a health care provider in the past two years reported at least one of these negative experiences with a provider or during a health care visit, compared to one-third (33%) of non-LGBT+ people. LGBT+ people were twice as likely as non-LGBT+ people to report that they had been discriminated against during a health care visit over the past two years (12% v. 6%).

Among LGBT+ people, these negative provider experiences were more commonly reported by women, younger groups, those with low incomes, and those with a disability or chronic disease. Large shares, in most cases more than half, of LGBT+ people in these groups reported having at least one of these negative provider experiences in the past two years (Table 5).

Communication is an important component of health care quality but three in ten (29%) LGBT+ people said it is difficult to find a doctor who explains things in a way that is easy to understand, higher than the share of non-LGBT+ people (19%) (Figure 14).

• LGBT+ people who were younger, low-income, and had Medicaid coverage or were uninsured had more difficulty finding a doctor who provides clear explanations than those who were older, higher income, or had private insurance.

Health Care Costs

LGBT+ people reported having problems with health care costs at similar rates as non-LGBT+ people, with nearly one-third (29%) of LGBT+ people and one-quarter (25%) of non-LGBT+ people reporting they or a household member had problems paying medical bills in the past 12 months (Figure 15). Given that LGBT+ people tend to be younger, have lower incomes, and have greater health needs, costs could be an outsized barrier to care for this group.

• Among LGBT+ people, this challenge was especially acute for those who reported being in fair or poor health, with 42% saying they have had problems paying medical bills.
• Not surprisingly, those with low incomes, the uninsured, and those in fair or poor health reported these challenges at higher rates than their counterparts but there were no statistically significant differences by gender.

Medical bills have consequences on LGBT+ people’s financial well-being, including their ability to afford basic necessities.

• Among the 29% LGBT+ people who reported having trouble paying medical bills in the past 12 months, six in ten (61%) said they used up all or most of their savings (Figure 16). About the same share said they had to set up a payment plan with a doctor or hospital (59%) or had difficulty paying for basic necessities (57%), and over half (53%) said they have been contacted by a collection agency, while 47% said they borrowed money from family or friends as a result of these bills. Non-LGBT+ people experience these consequences at similar rates.

Conclusion

While in many cases LGBT+ people have similar health and health care experiences to non-LGBT+ people, we find some notable differences. For example, LGBT+ people’s self-reported health status was poorer than non-LGBT+ people, despite being a younger population. They also reported wider prescription usage, and younger LGBT+ people reported higher rates of disability than younger non-LGBT+ people. Additionally, LGBT+ people reported a higher need for mental health services, which could relate to ongoing experiences of stigma and discrimination. Indeed, LGBT+ people reported higher rates of discrimination during a health care visit and were more likely to report a range of recent negative provider experiences, most commonly among LGBT+ women, those who were younger, had low incomes, and reported a disability or chronic disease. These experiences suggest a gap in clinical attention and/or competency for reaching LGBT+ people, especially those with intersecting marginalized identities.

More broadly, while data collection on LGBT+ people is improving, particularly at the federal level, it is still not standard, and as such, knowledge gaps remain, including with respect to health status, health needs, and health care access. Lack of research in this area limits the ability of those in both policy and health care sectors to address health needs and disparities within the LGBT+ population. As efforts aimed at limiting LGBT+ people’s access to social institutions, including health care, increase, continuing to monitor the community’s well-being and responding to discrimination and health challenges is especially timely.

Methods

Data for this issue brief come from the 2022 KFF Women’s Health Survey, a nationally representative survey of 6,442 people of all genders ages 18 to 64, including 958 LGBT+ people, conducted from May 10, 2022, to June 7, 2022. The objective of the survey is to help better understand respondents’ experiences with contraception, potential barriers to health care access, and other issues related to reproductive health. The survey was designed and analyzed by researchers at KFF (Kaiser Family Foundation) and fielded online and by telephone by SSRS using its Opinion Panel, supplemented with sample from IPSOS’s KnowledgePanel.

The survey asked respondents which sex they were assigned at birth, on their original birth certificate (male or female). They were then asked what their current gender is (man, woman, transgender, non-binary, or other). Those who identified as transgender men are coded as men and transgender women are coded as women. While we attempted to be as inclusive as possible and recognize the importance of better understanding the health of non-cisgendered people, as is common in many nationally representative surveys, we did not have a sufficient sample size (n >= 100) to report gender breakouts other than men and women with confidence that they reflect the larger non-cisgender population as a whole. The data in our reproductive health analyses use the respondent’s sex assigned at birth (inclusive of all genders) to account for reproductive health needs/capacity (e.g., ever been pregnant) while other analyses use the respondent’s gender (inclusive of males and females).

For this survey, LGBT+ people include those who identified their sexual orientation as lesbian, gay, bisexual, or “something else,” and those who identified their gender as transgender, non-binary, “other,” or whose reported gender does not correspond to their reported sex assigned at birth.

Sample design

The majority of respondents completed the survey using the SSRS Opinion Panel (n=5,202), a nationally representative probability-based panel where panel members are recruited in one of two ways: (1) through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Group through the U.S. Postal Service’s Computerized Delivery Sequence. (2) from a dual-framed random digit dial (RDD) sample provided by Marketing Systems Group.

In order to have large enough sample sizes for certain subgroups (females ages 18 to 35, particularly females in the following subgroups: lesbian/gay/bisexual; Asian; Black; Hispanic; Medicaid enrollees; low-income; and rural), an additional 1,240 surveys were conducted using the IPSOS KnowledgePanel, a nationally representative probability-based panel recruited using a stratified ABS design. (Note that due to small sample sizes, data for LGBT+ people who are Asian or Pacific Islanders are not presented in this report.)

Data collection

The majority of surveys completed using the SSRS Opinion Panel (n=5,056) and all of the surveys completed using the KnowledgePanel (n=1,240) were self-administered web surveys. Panelists were emailed an invitation, which included a unique passcode-embedded link, to complete the survey online. In appreciation for their participation, panelists received a modest incentive in the form of a $5 or $10 electronic gift card. In addition to the self-administered web survey, n=146 surveys were completed by telephone with SSRS Opinion Panelists who are web reluctant.

Weighting

The data are weighted to represent U.S. adults ages 18 to 64. The data include oversamples of females ages 18 to 35 and females ages 36 to 64. Due to this oversampling, the data were classified into three subgroups: females 18 to 35, females 36 to 64, and males 18 to 64. The weighting consisted of two stages: 1) application of base weights and 2) calibration to population parameters. Each subgroup was calibrated separately, then the groups were put into their proper proportions relative to their size in the population.

Calibration to Population Benchmarks

The total sample for the Women’s Health Survey was balanced to match estimates of each of the three subgroups (females ages 18 to 35, females ages 36 to 64, and males ages 18 to 64) along the following dimensions: age; education (less than a high school graduate, high school graduate, some college, four-year college or more); region (Northeast, Midwest, South, West); and race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic-born in U.S., Hispanic-born Outside the U.S., Asian non-Hispanic, Other non-Hispanic). The sample was weighted within race (White, non-Hispanic; Black, non-Hispanic; Hispanic; and Asian) to match population estimates. Benchmark distributions were derived from 2021 Current Population Survey (CPS) data. Although the LGBT+ sample in this survey is not weighted separately to match population benchmarks, the full sample is. Comparisons to the available demographic data for the LGBT population from the 2021 Behavioral Risk Factor Surveillance System (BRFSS) found the demographics from our sample closely align with the federal data source.

Margin of Sampling Error

The margin of sampling error, including the design effect for subgroups, is presented in Table 1 below. It is important to remember that the sampling fluctuations captured in the margin of error are only one possible source of error in a survey estimate and there may be other unmeasured error in this or any other survey.

The KFF Women’s Health Survey sample includes people of all genders; however, our sample design is more heavily focused on women. While our survey weights take this gender imbalance into account and we use additional data control measures to ensure the data we present are as reliable and as representative of the population as possible, some data points for certain subgroups with larger margins of error may be more heavily weighted by women than men. Caution should be exercised in interpreting findings among LGBT+ subpopulations due to smaller sample sizes and larger margins of error. Our issue briefs do not present data for subgroups where data limitations precluded us from developing reliable estimates.

STATISTICAL SIGNIFICANCE

All statistical tests are performed at the .05 confidence level. Statistical tests for a given subgroup are tested against the reference group (Ref.) unless otherwise indicated. For example, White is the standard reference for race/ethnicity comparisons and private insurance is the standard reference for types of insurance coverage. Some breakouts by subsets have a large standard error, meaning that sometimes even large differences between estimates are not statistically different.

See the full 2022 KFF Women’s Health Survey methodology for more details. The full survey instrument is available upon request.

1. The LGBT+ sample from the 2022 KFF Womenu2019s Health Survey includes 60% of whom are ages 18-34, which is younger than the non-LGBT+ sample but closely matches the U.S. Census Bureauu2019s Household Pulse survey data. ↩︎
2. This survey defines low income as household income under 200% of the federal poverty level (FPL); higher income is 200% or more of the FPL. The federal poverty level (FPL) for an individual in 2022 was $13,590. ↩︎
3. Survey respondents who reported being assigned female at birth were asked if they had either a general check-up or a well-woman visit. All others were asked if they had had a general check-up. ↩︎
4. Questions related to reproductive capacity (e.g., ever been pregnant) are based on the respondentu2019s sex assigned at birth (inclusive of all genders) while other analyses use the respondentu2019s gender (inclusive of males and females). ↩︎
5. Questions related to reproductive capacity (e.g., ever been pregnant) are based on the respondentu2019s sex assigned at birth (inclusive of all genders) while other analyses use the respondentu2019s gender (inclusive of males and females). ↩︎

A substantial body of research has investigated effects of the Affordable Care Act (ACA) Medicaid expansion, adopted by all but 10 states as of June 2023. Prior KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers; these generally positive findings persist even as more recent research considers increasingly complex and specific outcomes. This research provides context for ongoing debates about whether to expand Medicaid in states that have not done so already, where coverage options for many low-income adults are limited and nearly two million individuals fall into a coverage gap.

Medicaid is the largest source of public funding for family planning services—which are a mandatory benefit within the program—and finances 4 in 10 births in the United States, as well as provides prenatal and postpartum coverage. Federal law requires all states, including those that have not expanded Medicaid, to provide Medicaid coverage to pregnant individuals with incomes up to at least 138% of the federal poverty level (FPL). However, coverage options for the pre-pregnancy and postpartum periods vary across states and are more limited in non-expansion states. Nationwide, nearly 900,000 women fall into the coverage gap in non-expansion states.¹ 

This brief updates prior KFF literature reviews by summarizing 40 studies published between April 2021 and June 2023 on the impacts of Medicaid expansion on a range of sexual and reproductive health outcomes, including:

• health insurance coverage before, during, and after pregnancy;
• maternal and infant health access, utilization, and outcomes;
• family planning; and
• HIV care and prevention.

Consistent with prior research, recent studies identify positive effects of Medicaid expansion on coverage rates before, during, and after pregnancy; access to prenatal and postpartum care; birth and postpartum outcomes; use of the most effective contraceptive methods; and HIV screening and outcomes.

Our methodology is consistent with that of prior analyses. We conducted keyword searches of PubMed and other academic/health policy search engines to collect credible studies (published by a journal or by a nonpartisan research organization) on the impacts of the ACA Medicaid expansion. We then reviewed study abstracts to identify relevancy to sexual and reproductive health. Included study findings fall into four topic areas (Figure 1). Within each topic area, we first briefly summarize findings from earlier research (published between January 2014 and March 2021) and then highlight key findings from recent research that add to this body of evidence. For more information about earlier studies, see the 2021 and 2020 literature reviews. For citations from April 2021 through June 2023, see the Bibliography.

Insurance Coverage Before, During, and After Pregnancy

Prior studies overwhelmingly found that expansion increased postpartum coverage rates, as well as coverage prior to and during pregnancy. Although the American Rescue Plan Act of 2021 created a new option to expand postpartum coverage to 12 months via a State Plan Amendment, current federal statute requires that pregnancy-related Medicaid coverage continue through just 60 days. Earlier research indicates that ACA Medicaid expansion has decreased coverage loss after this 60-day period ends: all prior studies that consider rates of insurance coverage after pregnancy find that expansion significantly increased postpartum coverage. Studies also suggest an association between expansion and increased coverage prior to and during pregnancy.

Most recent studies continue to find that expansion is associated with coverage gains in the pre-pregnancy, pregnancy, and postpartum periods. All recent studies that consider the impact of expansion on insurance coverage prior to conception and at birth find coverage gains.^{2 ,3 ,4 ,5}  Also, four studies find increases in coverage during the postpartum period, including one that also found that racial disparities in such coverage decreased.^{6 ,7 ,8 ,9}  One study considered Medicaid coverage post-abortion in Oregon and found a significant increase, as well as significant declines in lapses in enrollment.¹⁰  In contrast, two studies had mixed findings and found that postpartum coverage gains were not significant.^11 ,12 

Maternal and Infant Health: Access, Utilization, and Outcomes

Prior studies found that expansion increased access to health care for pregnant and postpartum women, and some suggested improvements in certain adverse pregnancy outcomes. Studies find that expansion increased access to and utilization of prenatal services—such as medications to treat opioid use disorder (MOUD) during pregnancy—as well as postpartum care. Additionally, all prior studies that consider impacts on maternal mortality or morbidity find significant declines, though findings on the impact of expansion on other health outcomes during pregnancy are mixed. Studies generally suggest an association between expansion and improvements in infant birth outcomes such as low birthweight, but most find no impact on infant mortality or find that improvements in infant mortality were concentrated among non-White infants.

Consistent with previous research, recent studies find that expansion is associated with increased access to and utilization of prenatal and postpartum care. Most studies in this area find that expansion resulted in increased utilization of at least one prenatal or postpartum service.^{13 ,14 ,15 ,16 ,17 ,18 ,19 ,20}  These findings include increased use of services during pregnancy or childbirth, such as receipt of adequate prenatal care (both prior to and during the COVID-19 pandemic) and of MOUD, as well as of services during the postpartum period, such as breast pump claims and treatment for postpartum depression. Additionally, two studies find that Medicaid expansion may have promoted access to obstetrician-gynecologist (OB-GYN) care: by increasing the likelihood that OB-GYN practices have onsite resources to address psychosocial needs, and by facilitating access to intrapartum care for White and Hispanic women living in rural counties with obstetric unit closures.^21 ,22  A smaller number of studies find no impact of expansion on utilization of certain prenatal/postpartum services (such as early prenatal care), nor on access to providers (such as hospital-based obstetric units).^{23 ,24 ,25 ,26 ,27 ,28} 

Recent studies on the impact of expansion on adverse outcomes during pregnancy, birth, or postpartum are mixed. Several studies identify that expansion is associated with improvements in at least one health outcome.^{29 ,30 ,31 ,32 ,33}  These findings include decreased incidence of adverse outcomes prior to pregnancy and at birth:

• Improved pre-pregnancy health outcomes: One study found that expansion was associated with significant declines in self-reported pre-pregnancy depression.³⁴ 
• Improved maternal outcomes at childbirth: Consistent with prior research, one recent study considering maternal morbidity in New York found a significant decrease in incidence, and that this decrease was significantly greater for low- versus high-income women.³⁵ 
• Improved infant outcomes at childbirth: Two studies found that expansion was associated with lower rates of infant mortality (one of which identified a particular impact among Hispanic infants, similar to earlier research).^36 ,37  One study found that expansion decreased the rate of low birth weight among infants born to mothers with hypertension in pregnancy.³⁸  Finally, one study found that expansion reduced racial/ethnic disparities in infant health following rural obstetric unit closures.³⁹ 

However, a similar number of studies find no impact of expansion on certain pregnancy or postpartum health outcomes, including incidences of gestational hypertension/diabetes and of postpartum depressive symptoms.^{40 ,41 ,42 ,43 ,44 ,45 ,46} 

Family Planning

Prior literature reviews indicated that expansion increased utilization of the most effective contraception methods but had little or no effect on overall contraception use. Medicaid is the primary funding source for family planning services for low-income people, with state programs required to cover all prescription contraceptives. Although the literature generally indicates that expansion has had little effect on contraception use overall, numerous studies identify an increased use of the most effective, long-acting reversible contraception (LARC), which includes IUDs and implants.

Recent studies find that expansion increased rates of LARC utilization and may have increased overall contraception use among some populations. Recent studies identify increases in utilization of LARC, short-acting contraception, and overall contraception for certain populations.^{47 ,48 ,49 ,50 ,51 ,52} 

• Increased LARC utilization: Three studies find increased use of LARC: among all Medicaid enrollees, among postpartum individuals, and among sexually active high school students.^53 ,54 ,55 
• Increased short-acting contraception utilization: One study found that physicians in Medicaid expansion states provided significantly more enrollees with short-acting hormonal birth control methods compared to physicians in non-expansion states.⁵⁶ 
• Increased contraception utilization overall (short- and long-acting): One study found a significant increase in the use of any postpartum contraception method, driven by a shift from short-acting and non-prescription contraceptive methods to higher-cost, more effective forms of contraception.⁵⁷  Two studies pointed to increased use of contraceptive services and counseling among Medicaid-enrolled women of reproductive age in Oregon.^58 ,59 

Finally, consistent with earlier research, two studies found no significant impact of expansion on overall contraception use for certain populations (students and postpartum individuals).^60 ,61  Another study found that physicians in expansion and non-expansion states provided similar numbers of enrollees with LARC methods in 2016.⁶² 

A couple of recent studies suggest that increased access to family planning care after expansion may have decreased birth rates and short interpregnancy intervals, but others find no effect on these outcomes. One study found that expansion resulted in an overall decrease in live births among low-income women of reproductive age, particularly among subgroups with historically higher rates of unintended pregnancy (including unmarried, Hispanic, and American Indian and Alaskan Native women).⁶³  Another study found that expansion resulted in a decreased risk of short interpregnancy intervals (less than 12 months between births), which the authors note have a known association with poor maternal and infant health outcomes.⁶⁴  In contrast, three other studies find no impact of expansion on these or similar outcomes, including one study that found no impact on overall rates of early postpartum pregnancies but that such pregnancies did significantly decrease among Black patients.^65 ,66 ,67 

HIV Care and Prevention Outcomes

Prior studies suggest that expansion increased rates of HIV screening as well as health outcomes for those diagnosed with HIV. Prior to the ACA, many people with HIV faced limited access to insurance coverage. Research finds that expansion increased insurance coverage rates among people with or at risk of HIV. Prior studies also indicate that expansion led to increases in HIV test and diagnosis rates despite no change in actual HIV incidence. Finally, studies find that expansion is associated with increased utilization of Pre-Exposure Prophylaxis (PrEP) to prevent HIV and improved quality of care for patients with HIV.

Most recent studies continue to find positive effects of expansion on HIV screening rates and outcomes.⁶⁸  Consistent with prior research, recent studies find an association between expansion and increased rates of HIV testing.^69 ,70  Also, a study found significant coverage gains among women with or at risk of contracting HIV.⁷¹  Two studies on Medicaid expansion and PrEP both found positive impacts. The first found a small but significant increase in the likelihood that men (and transgender or nonbinary individuals) who have sex with men (MSM) were taking PrEP to prevent HIV.⁷²  The second found that Medicaid expansion was associated with a higher share of Google searches for PrEP keywords, potentially indicating an higher awareness of and interest in PrEP due to increased access.⁷³  Finally, a study that following expansion, people with HIV experienced a significant increase in linkages to care after diagnosis, but no change in viral suppression of HIV (which the authors note could be in part because of state variation in Medicaid coverage policies for people with HIV).⁷⁴ 

Emerging Research

A small number of additional emerging studies include findings on:

Abortion: The Hyde Amendment blocks states from using federal funds to pay for abortion services under Medicaid in most instances.⁷⁵  However, 17 states (all of which have expanded Medicaid) use state-only Medicaid funds to cover all or most medically accessible abortions. A recent study found no impact of Medicaid expansion on the abortion rate nationwide, though the authors note that this analysis was exploratory and that future research on expansion’s impact on abortions is necessary.⁷⁶  Research in this area may continue particularly as abortion access across states continues to evolve following the Dobbs v. Jackson Women’s Health Organization decision.

LGBTQ+ individuals: Earlier research found gains in Medicaid coverage among lesbian, gay, and bisexual individuals following expansion. Similarly, one recent study found that following Medicaid expansion, overall insurance coverage rates increased for low-income individuals in same-sex couples, with larger gains for women versus men. The study also noted no significant impact on the likelihood of being employed for either low-income men or women in same-sex couples.⁷⁷  Another study found that Medicaid expansion was associated with higher odds of having health coverage among transgender adults.⁷⁸ 

Taken together, the 40 new studies summarized in this brief add to the body of prior research finding positive effects of expansion on sexual and reproductive health. This research provides context for ongoing debates about whether to expand Medicaid in states that have not done so already. As states unwind the pandemic-era continuous enrollment provision in 2023, many individuals who qualified for Medicaid through the pregnancy pathway during the pandemic are at risk of losing Medicaid coverage. These individuals will have more coverage options in states that have expanded Medicaid. Looking ahead, future research may consider the impacts of expansion against the backdrop of evolving national and state landscapes around Medicaid eligibility as well as access to reproductive health care.

Bibliography, April 2021 to June 2023

Bibliography (.pdf)

1. KFF analysis of 2021 American Community Survey (ACS). ↩︎
2. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
3. Jean Guglielminotti, Ruth Landau, and Guohua Li, “The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations,” Anesthesia & Analgesia 133 no. 2 (August 2021): 340-348, https://doi.org/10.1213/ANE.0000000000005371 ↩︎
4. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
5. Bradley Corallo and Brittni Frederiksen, How Does the ACA Expansion Affect Medicaid Coverage Before and During Pregnancy? (Washington, DC: KFF, October 2022), https://modern.kff.org/medicaid/issue-brief/how-does-the-aca-expansion-affect-medicaid-coverage-before-and-during-pregnancy/ ↩︎
6. Lindsey Rose Bullinger, Kosali Simon, and Brownsyne Tucker Edmonds, “Coverage Effects of the ACA’s Medicaid Expansion on Adult Reproductive-Aged Women, Postpartum Mothers, and Mothers with Older Children,” Maternal and Child Health Journal 26 (March 2022): 1104-1114, https://doi.org/10.1007/s10995-022-03384-8 ↩︎
7. Maria Steenland, Ira Wilson, and Kristen Matteson, “Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities,” JAMA Health Forum 2 no. 12 (December 2021), https://doi.org/10.1001/jamahealthforum.2021.4167 ↩︎
8. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
9. Bradley Corallo, Jennifer Tolbert, Heather Saunders, and Brittni Frederiksen, Medicaid Enrollment Patterns During the Postpartum Year (Washington, DC: KFF, July 2022), https://modern.kff.org/medicaid/issue-brief/medicaid-enrollment-patterns-during-the-postpartum-year/ ↩︎
10. Susannah E. Gibbs and S. Marie Harvey, “Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon,” Journal of Women’s Health 31 no. 1 (January 2022): 55-62, https://doi.org/10.1089/jwh.2020.8941 ↩︎
11. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
12. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
13. Summer Hawkins, Krisztina Horvath, Alice Noble, and Christopher Baum, “ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance,” Women’s Health Issues 32 no. 2 (March 2022): 114-121, https://www.whijournal.com/article/S1049-3867(21)00158-4/fulltext ↩︎
14. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
15. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
16. Maria Steenland, Ira Wilson, and Kristen Matteson, “Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities,” JAMA Health Forum 2 no. 12 (December 2021), https://doi.org/10.1001/jamahealthforum.2021.4167 ↩︎
17. Sugy Choi et al., “Estimating The Impact on Initiating Medications for Opioid Use Disorder of State Policies Expanding Medicaid and Prohibiting Substance Use During Pregnancy,” Drug and Alcohol Dependence 129 pt. A (December 2021), https://www.sciencedirect.com/science/article/abs/pii/S0376871621006578 ↩︎
18. Maria Steenland and Amal Trivedi, “Association of Medicaid Expansion With Postpartum Depression Treatment in Arkansas,” JAMA Health Forum 4 no. 2 (February 2023), https://doi.org/10.1001/jamahealthforum.2022.5603 ↩︎
19. Pinka Chatterji, Hanna Glenn, Sara Markowitz, and Jennifer Karas Montez, ACA Medicaid Expansions and Maternal Morbidity (National Bureau of Economic Research, Working Paper No. 30770, December 2022), https://www.nber.org/papers/w30770 ↩︎
20. Hyunjung Lee and Gopal Singh, “The Differential Impact of the COVID-19 Pandemic on Prenatal Care Utilization Among US Women by Medicaid Expansion and Race and Ethnicity,” Journal of Public Health Management and Practice Epub ahead of print (December 2022), https://doi.org/10.1097/PHH.0000000000001698 ↩︎
21. Gabriela Weigel, Brittni Frederiksen, Usha Ranji, and Alina Salganicoff, “Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists,” Journal of Women’s Health 31 no. 6 (June 2022): 887-894, https://doi.org/10.1089/jwh.2021.0236 However, this study found no significant impact of expansion on the likelihood that OB-GYN practices report actually screening all patients for these needs. ↩︎
22. Pinka Chatterji, Chun-Yu Ho, and Xue Wu, Obstetric Unit Closures and Racial/Ethnic Disparity in Health (National Bureau of Economic Research, Working Paper No. 30986, February 2023), https://www.nber.org/papers/w30986 ↩︎
23. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
24. Claire Margerison, Robert Kaestner, Jiajia Chen, and Colleen MacCallum-Bridgers, “Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes,” American Journal of Epidemiology 190 no. 8 (August 2021): 1488-1498, https://doi.org/10.1093/aje/kwaa289 ↩︎
25. Maria Steenland, Ira Wilson, and Kristen Matteson, “Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities,” JAMA Health Forum 2 no. 12 (December 2021), https://doi.org/10.1001/jamahealthforum.2021.4167 ↩︎
26. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
27. Gabriela Weigel, Brittni Frederiksen, Usha Ranji, and Alina Salganicoff, “Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists,” Journal of Women’s Health 31 no. 6 (June 2022): 887-894, https://doi.org/10.1089/jwh.2021.0236 ↩︎
28. Caitlin Carroll, Julia Interrante, Jamie Daw, and Katy Backes Kozhimannil, “Association Between Medicaid Expansion and Closure of Hospital-Based Obstetric Services,” Health Affairs 41 no. 4 (April 2022), https://doi.org/10.1377/hlthaff.2021.01478 ↩︎
29. Jean Guglielminotti, Ruth Landau, and Guohua Li, “The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations,” Anesthesia & Analgesia 133 no. 2 (August 2021): 340-348, https://doi.org/10.1213/ANE.0000000000005371 ↩︎
30. Joanne Constantin and George Wehby, “Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity,” American Journal of Preventive Medicine 64 no. 3 (March 2023): 377-384, https://www.ajpmonline.org/article/S0749-3797(22)00498-6/fulltext ↩︎
31. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
32. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
33. Maria Steenland and Laura Wherry, “Medicaid Expansion Led To Reductions In Postpartum Hospitalizations,” Health Affairs 42 no. 1 (January 2023): 18-25, https://doi.org/10.1377/hlthaff.2022.00819 ↩︎
34. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
35. Jean Guglielminotti, Ruth Landau, and Guohua Li, “The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations,” Anesthesia & Analgesia 133 no. 2 (August 2021): 340-348, https://doi.org/10.1213/ANE.0000000000005371 In contrast, a national study (Chatterji et al. 2022), cited below, found no significant impact on severe maternal morbidity, but did not limit this analysis by income. ↩︎
36. Joanne Constantin and George Wehby, “Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity,” American Journal of Preventive Medicine 64 no. 3 (March 2023): 377-384, https://www.ajpmonline.org/article/S0749-3797(22)00498-6/fulltext ↩︎
37. Jessian Munoz, “Preterm Birth and Foetal-Neonatal Death Rates Associated With the Affordable Care Act Medicaid Expansion (2014–19),” Journal of Public Health 45 no. 1 (March 2023): 99–101, https://doi.org/10.1093/pubmed/fdab377 ↩︎
38. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
39. Pinka Chatterji, Chun-Yu Ho, and Xue Wu, Obstetric Unit Closures and Racial/Ethnic Disparity in Health (National Bureau of Economic Research, Working Paper No. 30986, February 2023), https://www.nber.org/papers/w30986 ↩︎
40. Joanne Constantin and George Wehby, “Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity,” American Journal of Preventive Medicine 64 no. 3 (March 2023): 377-384, https://www.ajpmonline.org/article/S0749-3797(22)00498-6/fulltext ↩︎
41. Claire E. Margerison, Katlyn Hettinger, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner, “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health,” Health Affairs 40 no. 10 (October 2021), https://doi.org/10.1377/hlthaff.2021.00776 ↩︎
42. Ian Everitt et al., “Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth,” Circulation: Cardiovasucular Quality and Outcomes 15 no. 1 (January 2022), https://doi.org/10.1161/CIRCOUTCOMES.121.008249 ↩︎
43. Claire Margerison, Robert Kaestner, Jiajia Chen, and Colleen MacCallum-Bridgers, “Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes,” American Journal of Epidemiology 190 no. 8 (August 2021): 1488-1498, https://doi.org/10.1093/aje/kwaa289 ↩︎
44. Anna Austin, Rebeccah Sokol, and Caroline Rowland, “Medicaid Expansion and Postpartum Depressive Symptoms: Evidence From the 2009-2018 Pregnancy Risk Assessment Monitoring System Survey,” Annals of Epidemiology 68 (April 2022): 9-15, https://www.sciencedirect.com/science/article/abs/pii/S1047279721003537 ↩︎
45. Maria Steenland and Laura Wherry, “Medicaid Expansion Led To Reductions In Postpartum Hospitalizations,” Health Affairs 42 no. 1 (January 2023): 18-25, https://doi.org/10.1377/hlthaff.2022.00819 ↩︎
46. Pinka Chatterji, Hanna Glenn, Sara Markowitz, and Jennifer Karas Montez, ACA Medicaid Expansions and Maternal Morbidity (National Bureau of Economic Research, Working Paper No. 30770, December 2022), https://www.nber.org/papers/w30770 ↩︎
47. Lydia Pace, Indrani Saran, and Summer Sherburne Hawkins, “Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine,” Medical Care 60 no. 2 (February 2022): 119-124, https://doi.org/10.1097/MLR.0000000000001666 ↩︎
48. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
49. Greta Kilmer et al., “Medicaid Expansion and Contraceptive Use Among Female High-School Students,” American Journal of Preventive Medicine 63 no. 4 (October 2022): 592-602, https://www.ajpmonline.org/article/S0749-3797(22)00244-6/fulltext ↩︎
50. Mandar Bodas et al., “Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries,” JAMA Health Forum 4 no. 3 (March 2023), https://doi.org/10.1001/jamahealthforum.2023.0106 ↩︎
51. Susannah E. Gibbs, S. Marie Harvey, Annie Larson, Jangho Yoon, and Jeff Luck, “Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program,” Journal of Women’s Health 30 no. 5 (May 2021): 750-757, https://doi.org/10.1089/jwh.2020.8351 ↩︎
52. Mandana Masoumirad, S. Marie Harvey, Linh N. Bui, and Jangho Yoon, “Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion,” Journal of Women’s Health 32 no. 3 (March 2023): 300-310, https://doi.org/10.1089/jwh.2022.0308 ↩︎
53. Lydia Pace, Indrani Saran, and Summer Sherburne Hawkins, “Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine,” Medical Care 60 no. 2 (February 2022): 119-124, https://doi.org/10.1097/MLR.0000000000001666 ↩︎
54. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
55. Greta Kilmer et al., “Medicaid Expansion and Contraceptive Use Among Female High-School Students,” American Journal of Preventive Medicine 63 no. 4 (October 2022): 592-602, https://www.ajpmonline.org/article/S0749-3797(22)00244-6/fulltext ↩︎
56. Mandar Bodas et al., “Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries,” JAMA Health Forum 4 no. 3 (March 2023), https://doi.org/10.1001/jamahealthforum.2023.0106 ↩︎
57. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
58. Susannah E. Gibbs, S. Marie Harvey, Annie Larson, Jangho Yoon, and Jeff Luck, “Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program,” Journal of Women’s Health 30 no. 5 (May 2021): 750-757, https://doi.org/10.1089/jwh.2020.8351 ↩︎
59. Mandana Masoumirad, S. Marie Harvey, Linh N. Bui, and Jangho Yoon, “Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion,” Journal of Women’s Health 32 no. 3 (March 2023): 300-310, https://doi.org/10.1089/jwh.2022.0308 ↩︎
60. Greta Kilmer et al., “Medicaid Expansion and Contraceptive Use Among Female High-School Students,” American Journal of Preventive Medicine 63 no. 4 (October 2022): 592-602, https://www.ajpmonline.org/article/S0749-3797(22)00244-6/fulltext ↩︎
61. Erica Eliason, Jamie Daw, and Heidi Allen, “Association of Medicaid vs Marketplace Eligibility With Maternal Coverage and Access to Prenatal and Postpartum Care,” JAMA Network Open 4 no. 12 (December 2021), https://doi.org/10.1001/jamanetworkopen.2021.37383 ↩︎
62. Mandar Bodas et al., “Association of Primary Care Physicians’ Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries,” JAMA Health Forum 4 no. 3 (March 2023), https://doi.org/10.1001/jamahealthforum.2023.0106 ↩︎
63. Erica L. Eliason, Jamie R. Daw, and Heidi L. Allen, “Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age,” Journal of Women’s Health 31 no. 7 (July 2022): 949-956, https://doi.org/10.1089/jwh.2021.0451 ↩︎
64. Kriya S. Patel, Juliana Bakk, Meredith Pensak, Emily DeFranco, “Influence of Medicaid Expansion on Short Interpregnancy Interval Rates in the United States,” American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine 3 no. 6 (November 2021), https://www.ajogmfm.org/article/S2589-9333(21)00179-8/fulltext ↩︎
65. Erica L. Eliason, Amanda Spishak-Thomas, and Maria W. Steenland, “Association of the Affordable Care Act Medicaid Expansions with Postpartum Contraceptive Use and Early Postpartum Pregnancy,” Contraception 113 (September 2022): 42-48, https://www.contraceptionjournal.org/article/S0010-7824(22)00060-9/fulltext ↩︎
66. Danielle Gartner, Robert Kaestner, and Claire Margerison, “Impacts of the Affordable Care Act’s Medicaid Expansion on Live Births,” Epidemiology 33 no. 3 (May 2022): 406-414, https://doi.org/10.1097/EDE.0000000000001462 ↩︎
67. Can Liu et al., “Impact of Medicaid Expansion on Interpregnancy Interval,” Womens Health Issues 32 no. 3 (May 2022): 226-234, https://www.whijournal.com/article/S1049-3867(21)00190-0/fulltext ↩︎
68. Consistent with prior analysis, note that study findings on screening and outcomes related to HPV, as well as gynecological cancer generally, are included in our discussion of research on the impact of expansion on cancer-related outcomes. ↩︎
69. Suhang Song and James Kucik, “Trends in the Impact of Medicaid Expansion on the Use of Clinical Preventive Services,” American Journal of Preventive Medicine 62 no. 5 (May 2022): 752-762, https://www.ajpmonline.org/article/S0749-3797(21)00595-X/fulltext ↩︎
70. Toni Romero and Branco Ponomariov, “The Effect of Medicaid Expansion on Access to Healthcare, Health Behaviors and Health Outcomes Between Expansion and Non-Expansion States,” Evaluation and Program Planning Epub ahead of print (May 2023), https://doi.org/10.1016/j.evalprogplan.2023.102304 ↩︎
71. Andrew Edmonds et al., “Impacts of Medicaid Expansion on Health Insurance and Coverage Transitions among Women with or at Risk for HIV in the United States,” Womens Health Issues 32 no. 5 (September-October 2022): 450-460, https://www.whijournal.com/article/S1049-3867(22)00027-5/fulltext ↩︎
72. Pedro Botti Carneiro et al., “Demographic, Clinical Guideline Criteria, Medicaid Expansion and State of Residency: a Multilevel Analysis of PrEP Use on a Large US Sample,” BMJ Open 12 no. 2 (February 2022), https://bmjopen.bmj.com/content/12/2/e055487.info ↩︎
73. Bita Fayaz Farkhad, Mohammadreza Nazari, Man-pui Sally Chan, and Dolores Albarracín, “State Health Policies and Interest in PrEP: Evidence from Google Trends,” AIDS Care 34 no. 3 (2022): 331-339, https://doi.org/10.1080/09540121.2021.1934381 ↩︎
74. J. Logan et al., “HIV Care Outcomes in Relation to Racial Redlining and Structural Factors Affecting Medical Care Access Among Black and White Persons with Diagnosed HIV—United States, 2017,” AIDS and Behavior 26 (March 2022): 2941–2953, https://doi.org/10.1007/s10461-022-03641-5 ↩︎
75. The Hyde amendment includes exceptions for pregnancies that are the result of rape, incest, or if the pregnant person’s life is in danger. ↩︎
76. In particular, the abortion analysis was not restricted to women with Medicaid-eligible incomes and was not limited to only states that cover abortions in Medicaid. Erica L. Eliason, Jamie R. Daw, and Heidi L. Allen, “Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age,” Journal of Women’s Health 31 no. 7 (July 2022): 949-956, https://doi.org/10.1089/jwh.2021.0451 ↩︎
77. Samuel Mann et al., “Effects of the Affordable Care Act’s Medicaid Expansion on Health Insurance Coverage for Individuals in Same-sex Couples,” Health Services Research 58 no. 3 (June 2023): 612-621, https://doi.org/10.1111/1475-6773.14128 ↩︎
78. Nguyen Tran, Kellan Baker, Elle Lett, and Ayden Scheim, “State-Level Heterogeneity in Associations Between Structural Stigma and Individual Health Care Access: A Multilevel Analysis of Transgender Adults in the United States,” Journal of Health Services Research & Policy 28 no. 2 (April 2023): 109-118, https://doi.org/10.1177/13558196221123413 ↩︎