"Repealing this law would really destabilize the market and it would throw the health system into chaos,” said Cindy Zeldin, who leads the group Georgians for A Healthy Future. “And the…
By Em Elliott, Jeff Graham, and Amanda Ptashkin
Georgia Equality and Georgians for a Healthy Future have been working together within the larger Cover Georgia coalition to educate and advocate on the issue of Medicaid in Georgia. Under the Affordable Care Act, states have the option to create a new category of eligibility for Medicaid to cover low-income individuals and families, financed almost entirely with federal dollars. Implementing this expansion is the only viable way to cover Georgia’s low-income uninsured, and it will pump resources into our state’s healthcare delivery system. Many other states are also advocating for expansion and Community Catalyst, a national health care reform advocacy organization, came to us with some questions around advocacy, lessons on collaborative partnerships, and the way this issue effects the LGBTQ community.
Can you give us a bit of background on Georgia’s LGBT population?
Based on the 2010 census data, the Williams Institute estimates that there are 293,932 gay, lesbian, and bisexual people living in Georgia. We round this up to over 300,000 to include population increases and estimates for transgender individuals. As you can see on the map, there are LGBT individuals living in every corner of the state and not just concentrated in the Atlanta area like some may think.
How was the partnership between Georgians for a Healthy Future (GHF) and Georgia Equality initiated? What sparked it?
Georgia Equality’s Executive Director is one of the founding members of GHF, so there has been a strong relationship between the two organizations from GHF’s beginning. From the time that the Affordable Care Act (ACA) was first passed, GHF and GE have often worked together to present educational programs for the HIV community. A year ago, the two organizations started talking about ways to expand this working history to include more of the LGBT community. GHF’s mission of including the perspectives of Georgia’s diverse population in issues related to health policy is a natural complement to GE’s mission of ensuring that the needs of LGBT Georgians are recognized in all aspects of public policy.
What’s been the focus of your collaborative work? How did you decide this?
Much of our work over the past few months has focused on engaging the LGBT community and the HIV/AIDS community in the advocacy efforts to expand Medicaid in Georgia. Intentionally leaving over half a million Georgians uninsured is not only bad public policy, it also does not make sense from an economic perspective. Georgia’s economy has not rebounded at the rate that other states have seen and far too many of our citizens remain unemployed and underemployed. This is an issue of basic human rights, economic justice and good public health. Both GHF and GE have been strong voices in the Cover Georgia coalition—a group of 60+ organizations, partners and stakeholders all committed to seeing Georgia expand coverage through Medicaid.
Why is the Medicaid expansion an important issue for GA’s LGBT population?
Medicaid expansion is critically important for the LGBT population here in Georgia. Already LGBT folks face higher health disparities and stigma within our healthcare system making access to culturally-competent care more difficult. LGBT people are more likely to be uninsured or low-income than their straight or cisgender peers so already there is a great need for health services and access in general. Over 65% of the LGBT Georgians who accessed The Health Initiative’s LGBT Health Fund for the uninsured in 2011 were folks eligible for Medicaid under the new expansion.
More specifically, under the ACA insurance plans can no longer discriminate on the basis of sex, gender identity, disability, diagnosis, and medical condition. Plans have to provide preventive screenings for everyone who needs them, regardless of the sex on their insurance card which is important for transgender and gender non-conforming folks. Same sex couples will also benefit as a new tool, finder.healthcare.gov will allow individuals to identify same-sex domestic partner coverage options. Couples can filter their search and easily eliminate plans that would not cover both of them.
Expansion has big benefits for people living with HIV as well. According to the National Alliance of State and Territorial AIDS Directors, up to 72% of people living with HIV/AIDS in Georgia would qualify for Medicaid. Not only would this solve the recurring problem of paying for medications through the AIDS Drug Assistance Program, it would create a new source of funding for providers and allow for greater choice of providers.
Also we worry about our young people; even now youth who come out as gay or transgender to their parents face rejection and homelessness in many cases. An estimate from the National Taskforce states that one in four youth who come out to their parents are kicked out of their home and no longer have access to their parent’s healthcare even if they are under the age of 26. Insurance provided through Medicaid would help these young people secure basic medical care if insurance through their parents is not an option.
As you can see, Medicaid expansion has huge impact on LGBT Georgians and there is a lot at stake for expansion.
How has Medicaid expansion work for LGBT communities touched on some issues that each organization was independently working on?
One of the ongoing issues that Georgia Equality works on is access to benefits. While this work primarily revolves around establishing domestic partner benefits from local governments, larger institutions or private businesses, the reality is that many people who identify as LGBT are not in the sort of long-term relationship that is needed to qualify for domestic partner benefits where they exist. Changing the basic structure of Medicaid so that it is based on income and not familial or health status allows us to work to protect those who are not in relationships or whose employers do not offer domestic partner benefits.
We also have been growing our work with youth and young adults. As we stated before, it is highly unlikely that a parent who rejects their child and kicks them out of their home would allow that child to stay on their health insurance plan. Therefore, Medicaid expansion also becomes the only source of coverage for many young LGBTQ identified people who may be struggling to stay in school or lack the type of full-time job that provides employer-based coverage.
What have been some unexpected surprises (both challenges and assets) to working with a statewide consumer health advocacy group?
Because Georgia Equality has already established a working relationship with GHF, it’s not really a surprise, however, GHF’s sensitivity to LGBT issues, flexibility in changing some their materials to be more inclusive and commitment to include us fully in their work has been such a relief. Certainly there are a number of main-stream organizations where this is an issue. It’s also been nice that we can focus on our area of expertise, which is LGBT issues, while using GHF as an expert on more general health policy and ACA implementation. In that way, our work complements each other nicely.
What Medicaid expansion messaging has resonated well with GA’s LGBT communities? Did you identify particular messaging that works better for some intersections of LGBT populations and specific communities of color, for example?
Talking about Medicaid expansion with the LGBT community has been very interesting. We have to spend time just educating our community on what is at stake, there is so much misinformation out there and it is such a complicated issue that often LGBT folks do not think this expansion would include them or benefit them in any way. We had to do a lot of basic myth-busting and general education with our community. More specifically, we have created messaging around LGBT youth for whom remaining on a parent’s insurance is not an option; for single people or couples who do not have access to domestic partner benefits and for those members of the LGBT community who are either self-employed or who work in industries such as the arts or hospitality that do not usually offer health insurance; and people who are living with HIV/AIDS. This project came together so quickly that we did not have the time to test specific messages but from the overwhelmingly positive response that we have received, especially from people of color, older adults and the transgender community, we’re confident that these messages have resonated with many segments of our community.
How has this work tied into some of your larger health equity work?
Working collaboratively with GHF and within the larger Medicaid expansion coalition has been an eye-opening experience and dovetails perfectly into our other healthcare goals. One example is our work around the Youth Risk Behavior Survey (YRBS). This is a survey conducted every two years for high school students across the nation. Georgia is one of only four states that currently does not include the seven basic sexual health questions in the YRBS. The data collected from the YRBS is used to inform policy and funding for many youth programs and we aren’t even asking the questions; we are losing valuable data as well as potential funding sources. Our work within the Medicaid expansion coalition gave us access to other health and youth partners who we did not have a relationship with before. With these new relationships we were able to participate in a meeting with the Governor’s staff and directly ask why they weren’t including these important health questions that would directly benefit young people in our state. This connection and advocacy opportunity may not have happened without us already being engaged in the Medicaid expansion work.
In another example, we are constantly working on increasing education on HIV and AIDS issues, as well as securing funding for programs such as AIDS Drug Assistance Program (ADAP) which provides life-saving medication for low-income people living with HIV who aren’t eligible for Medicaid under the current law. Georgia has higher rates of HIV transmission than the national average and we have been battling a waiting list for ADAP on and off for many years. Medicaid expansion would solve this ongoing problem by granting access to healthcare for more individuals.
Where do you see this collaboration going next?
Regardless of the outcome, this collaboration has been a hugely positive one for us and we hope to see our partnership continue beyond Medicaid expansion. Both groups have expertise in different areas and bring a lot to the table. We hope to harness this team for additional collaborations in the future that would benefit both organizations and a helpful ongoing relationship. One example would be around implementation of Medicaid once the state decides to expand the program. Specifically, we will need to leverage the power of GHF and other coalition partners to ensure that medical care for transgender individuals is included in the essential health benefits that would be designed as part of future expansion efforts.
Additionally, both GHF and GE/The Health Initiative are part of a consortium of organizations that wererecently awarded a grant from the Department of Health and Human Services to work on outreach, education and enrollment into the new health insurance marketplace. This further collaboration will ensure that we are addressing the needs of LGBT individuals in our state and ensuring they have access to the new offering of the marketplace, as well as the subsidies to help with the cost of coverage.
What are some lessons for other states?
Two lessons come to mind that could be helpful for other states:
The first is the need to tailor messaging directly to the LGBT community by using images and examples that are specific to this group. In far too many instances, mainstream organizations wonder why their outreach efforts to the LGBT community fail to generate much response. The LGBT community is so used to being ignored, undervalued or misunderstood that there is a hesitancy to feel included unless that inclusion is direct and visible. The LGBT groups will come if they feel that the outreach is genuine and the commitment to our issues is sincere.
The second lesson is that working with the LGBT community should not be seen as controversial. If we can be successful with these efforts in a conservative environment like Georgia, other mainstream organizations and coalitions can be successful in other parts of the country. There may be a need to do some education with boards or staff to ensure that the commitment is solid, but the public’s attitudes on a host of LGBT issues has changed dramatically in the past few years. Hopefully more mainstream groups will begin to appreciate the importance of including us as a community in their educational efforts and advocating for our needs in their policy work.