A Level Playing Field

The Obama administration has pledged millions of dollars to LGBT community health centers that help a population at greater risk of committing suicide, contracting HIV and being uninsured. What will happen after the election?

by 

October 14, 2012
The Department of Health and Human Services has given tens of millions of dollars in grant funding to LGBT community health centers. Photo by Nolan Feeney.

30 days.

That’s how long U.S. Secretary of Health and Human Services Kathleen Sebelius recently warned it would take for Republicans to undo LGBT progress of the last three years if Mitt Romney wins the presidential election in November. 

The past few years have seen a number of changes in the lives LGBT Americans, including the repeal of Don’t Ask, Don’t Tell and President Barack Obama’s endorsement of marriage equality. But in Sebelius’ department, there’s a lot of progress to be undone – and a lot funding that could trickle to a halt. Health and Human Services (HHS) has given tens of millions of dollars in landmark grant funding to LGBT health programs across the country.

Secretary of Health and Human Services
Kathleen Sebelius

“There's greater potential and likelihood of LGBT programs receiving public funds because this administration is giving a fair approach. It's giving fair consideration. It's inevitable that our programs will start to see funding,” Michael Adams says. He’s executive director of SAGE, Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders, which received a federal grant in 2010 to create the first national resource center for care providers serving aging LGBT communities. 

“Prior to President Obama coming into office in 2009, there was just not an open door about government support," Adams says. "It simply could not have been on the table in the Bush administration that preceded Obama. It was the arrival of President Obama that leveled the playing field and made it possible for LGBT health-related and aging programs to receive funding. It's not special treatment. It's about being treated fair and equally, and that wasn't happening.”

LGBT community health centers have benefitted in particular. The Administration for Children and Families, for example, promised $13.3 over five years to the L.A. Gay & Lesbian Center in 2010 to create a support program for LGBT foster youth, the largest federal grant ever allocated to an LGBT organization. Under budgets for expanding the operation of community health centers included in the Affordable Care Act, Chase Brexton Health Services in Baltimore and Fenway Health in Boston received $5 million and $3.7 million respectively as a part of a $728 million grant. 

Historically, community health centers have had bipartisan support ever since the Office of Economic Opportunity established them in 1965. But LGBT health was left out of the equation, until now.  

“HHS is doing amazing changes. Sebelius has been completely behind us,” says Scout, who goes by one name. He’s the fast-talking director of the Network for LGBT Health Equity at the Fenway Institute in Boston and a longtime advocate for improving LGBT health. 

Improving the health of a population means serving that community directly. Community health centers are a vital pillar of LGBT health for two reasons, says Nurit Shein, the executive director of Philadelphia’s Mazzoni Center, which received an HHS health center planning grant in 2011. Gender and sexual minorities sometimes find physicians to be clueless or difficult to talk to about their medical problems, and LGBT patients have less access to health care because of discrimination and lack of coverage offered for an employee’s partner. The number of free or discounted services that centers offer allow them to reach underserved populations that might have no other options.

“The importance of an LGBT health center is that we do not turn anybody away,” Shein says. “We are really the backbone for preventative care for younger people who have no access to health care.”

Since Barack Obama took office in 2009, LGBT health experts say it has been easier than ever to find a receptive audience at the White House. 

“Obama himself really can be most directly credited with creating a more LGBT-friendly audience across the administration,” Joseph Jefferson says. Jefferson is senior policy associate for the National Coalition for LGBT Health, which worked closely with the department of Health and Human Services during the drafting of the Affordable Care Act and now on the act’s implementation. “He offered very clear directions to all of the secretaries to engage with LGBT advocates.”

President Obama at the 2012 State of the Union.

Sebelius used authority granted under the Affordable Care Act to collect information about underserved communities and applied it to LGBT populations. Last year, she announced the country’s first ever health survey about gender identity and sexual orientation, a collaboration between her department and the Fenway Institute. The Centers for Disease Control also work with HHS on survey questions about the health needs of these populations. If researchers don’t document the scope and scale of the problems, some experts say, it becomes harder for LGBT health researchers and organizations to get into the funding pool and address them.

“You have these people going across the country and capturing snapshots of people's health, and they're entirely leaving out LGBT people in most of these surveys,” says Kellan Baker, a health policy analyst with the LGBT Research and Communications Project at the Center for American Progress. “That becomes the excuse of why there's no money, no programming, why nothing's happening. We don't really know what the problems are. Collecting data, building that evidence base is one of the most fundamental things you can do to advance LGBT health because it allows us to say where we are and where we're going.”

The Institute of Medicine, a non-governmental organization that independently advises policy makers on national health issues, came to a similar conclusion. In the spring 2011, it released a groundbreaking report on LGBT health. The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for a Better Understanding recommended that the federal government collect LGBT health data and called for greater federal funding of LGBT health research. It also recommended that the National Institutes of Health, which commissioned the report, encourage its grant applicants to address LGBT inclusion in their proposals. 

For years, issues in LGBT health meant one thing: HIV/AIDS. The disease has been and still is a major health issue facing many LGBT Americans, and the 2009 extension of the Ryan White CARE Act continues to fund care for people living with HIV/AIDS through clinics and health centers. But recent grant awards and the IOM report reflect a growing recognition that LGBT health encompasses a lot more than just one epidemic.

“People understand about substance abuse, about tobacco abuse, health and wellness issues,” Shein says. “There’s beginning to be an understanding in the federal government that there are other platforms that influence health such as homelessness, poverty, race and so on.”

LGBT populations also face a number of health disparities: Youth face higher rates of suicide; gay men, especially men of color, have greater risk of STD and HIV infection; lesbians are less likely to participate in preventative cancer services; LGBT Americans battle the highest rate of drug, alcohol and tobacco use; and transgender people are less likely to have health insurance and battle high rates of mental health issues and STD infection. Among LGBT seniors, health challenges include increased levels of mental health, substance abuse and types of cancer.

How the government recognizes and prioritizes these disparities varies. For the first time, HHS’s report on health goals for the decade, Healthy People 2020, includes LGBT Americans and openly discusses these inequalities. The National Institutes of Health (NIH) commissioned the IOM report and reviewed its body of LGBT research to identify areas for improvement among, but currently it does not consider LGBT Americans as one of the disparity populations it studies.

The NIH is a part of HHS, but it deals more with health science and research than the kind of programming that funds grants for health centers. Still, some experts say recognizing LGBT Americans as a disparity population would draw more attention to their health issues and, eventually, lead to more funding opportunities to address them.

“What’s disappointing is still LGBT is not specified as a special population, which makes it more difficult for us to apply for funding for LGBT issues,” Shein says.

Funding requirements have sometimes differed for organizations serving federally designated priority populations. A recent CDC preventative health fund required community organizations to have chapters in 85 percent of the country. Organizations that were designated as served racial and ethnic minorities, however, were only required to have chapters in four states. That's a significantly lower hurdle to clear, but LGBT organizations don't always see the same opportunities.

A few landmark grants accomplished during this administration don't go far enough in leveling the playing field, Scout says. Some corners of HHS, like the Administration for Children and Families and the Substance Abuse and Mental Health Administration, encourage LGBT action plans or even use them as a criterion for evaluating proposals. 

“What if they all had a plan for LGBT inclusion?” Scout says. “That would have made a huge difference.”

It can also be difficult for an LGBT health center to be designated as a Federally Qualified Health Center (FQHC), which makes it eligible for more federal grants and start-up funds. Achieving FQHC status is a very competitive process. LGBT centers don't always match the government's historic model of what a community health center is, and meeting the numerous requirements to become an FQHC can require a center to change its operations, especially if it is transitioning from an HIV/AIDS care operation to a more comprehensive care provider.

“As the LGBT center becomes more professional, more accountable and more compliant with federal rules and regulations, it may lose some of its former identity or brand in its community,” wrote Don Blanchon, the executive director of Whitman-Walker Health in Washington, D.C., in an email. “Some in the community will inevitably say that this LGBT center is ‘moving away from us’ by caring for a broader community under [FQHC] status. This can be a mission-critical question and pose real community relations and communication challenges for LGBT centers.”

Budget size can also be a major factor in determining access to funding, says Terry Stone, the executive director of CenterLink, which supports and develops LGBT community centers across the country and internationally. There’s no hard and fast rule, but often once centers’ operating budgets reach around $450,000 and higher, they generally have more access to federal funding. But that leaves out a lot of organizations that address health disparities.

“If you’re a small itty bitty community center, that automatically excludes you,” Stone says.

In other words, the restrictions may keep resources away from centers serving communities HHS is trying to reach. The complementary role of LGBT community centers, for example, is overlooked in grant funding, some health advocates say. More than 200 LGBT community centers exist in the U.S., as opposed to the dozen community health centers. Only eight of those community health centers explicitly mention caring for LGBT communities in their mission statement, and only seven of those have some form of a Federally Qualified Health Center designation. (An FQHC Look-Alike designation offers similar benefits but not the same access to funding.)

Community centers aren’t designed to provide primary health care, but they do play a key role in LGBT lives: A study published this summer by Movement Advanced Project and CenterLink, found that these centers serve 1.7 million people a year, and typically reach populations of racial minorities, transgender individuals and lower-income people. These centers can also offer services such as disease testing and screenings and support for mental health and substance abuse. 

These types of services and prevention make community centers an important part of the LGBT health in the U.S., Scout says. “Only about eight [LGBT community health centers] will be able to shoot for this huge expansion that’s shooting down the pipe,” he says. “The others [community centers] should be able to shoot for prevention work, but the way that’s rolling out, they can’t. The feds have to meet us in the middle.”

“This is more like when you throw a rock in the pond,” Scout says. “It takes a long time for the ripples to get all the way to the edge.”

And if there’s a sea change in the White House and Health and Human Services next January, LGBT health advocates fear they may not see that happen.