LGBTQ+ Inclusive Care, Part 2: Discussing Equitable Healthcare Access

At the Core of Care

Published: September 20, 2021

SARAH: This is At the Core of Care. A podcast where people share their stories about nurses and their creative efforts to better meet the health and health-care needs of patients, families, and communities.

I’m Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.

This is Part 2 of our special coverage about equitable access to health care. On this episode, we’re bringing you a conversation with Assistant United States Health Secretary Dr. Rachel Levine and Adrian Shanker.

We’re picking up from our previous episode, Part 1, which featured an in-depth healthcare consumer panel discussion moderated by Adrian about access to care for the LGBTQ community.

If you haven’t heard Part 1, I’d definitely recommend going back into our podcast feed and listening to that one first. It will help set the stage for the conversation you’re about to hear as we more broadly discuss equitable healthcare access...and common disparities that exist for racial, ethnic, and gender minorities.
As part of our conversation, we’re also going to address various ways in which our healthcare system could be better designed to promote equitable access to care and well-being. Including what happens when providers adopt cultural competency and humility in their practice and the roles that health education and research can play.

Before we delve in, just a bit about our guests. Dr. Levine is the 17th Assistant Secretary for Health for the United States Department of Health and Human Services or HHS. Prior to serving in this position, Dr. Levine was Pennsylvania’s Secretary of Health.
And Adrian Shanker is the executive director of the Bradbury-Sullivan LGBT Community Center, and the editor of Bodies and Barriers: Queer Activists on Health. And Dr. Levine actually wrote the forward for that book.

Welcome to you both and thanks so much for joining us on At the Core of Care. So let's start off talking about the concept of equitable health care access. We've been hearing this term a lot in recent years, and certainly during the COVID-19 pandemic that's come front and center. So for each of you, what does equitable healthcare access mean to you?

DR. LEVINE: Well, I'll start. We are in the midst of the largest pandemic that the world has seen since 1918. And I think that it is really incumbent upon us to learn lessons from the pandemic that will inform public health in the future. I think that the COVID-19 pandemic has certainly shown us is that the health and well-being of really everyone living in our country in the United States, but also globally, in countries around the world are interconnected, we are all interconnected. And the solutions to many of our healthcare challenges are interconnected as well. So we really have to work together to help each other and to protect each other, what happens to one person impacts another what happens to one community impacts another community. And we need to ensure that a healthier future really includes addressing and eliminating health disparities in promoting health equity.


ADRIAN: I would just add that, you know, if we've learned one thing from the COVID-19 pandemic, it's that all of us are only as healthy as everyone else around us when it comes to public health. And that means that if we live in communities where there's large groups of people who can't access, preventative health services, or who can't access, you know, health insurance in general, or access to care more broadly, that puts all of us at risk, not just that individual person. And what we do see is that there are many communities that are statistically less likely to access care, and access even healthcare information sometimes. And that's not only a problem for those historically excluded communities, it's actually a problem for our whole society. And these barriers to care are a literal stumbling blocks, not only that hold marginalized communities behind, but that keep our entire society from the unmet dream of health equity. If we want to achieve that dream of health equity, we have to work very hard to ensure that all of us have access to health care that our bodies deserve. SARAH:
We know that access to care disparities do continue to exist for racial, ethnic, and gender minorities. And from your perspective, where do we, as a society, need to concentrate our efforts most immediately to see some actionable change? What does that change look like? DR. LEVINE: It's very clear that the COVID-19 pandemic has impacted some communities far more than others. And that fact underscores the profound disparities in health that have really plagued our nation for far too long. It's not a new issue. The COVID-19 pandemic has brought even into even sharper focus to health disparities, for example, of the African American community of the Latin x community, and the American Indian and Alaskan Native community, and other historically underserved communities, including the LGBTQ community. We also aware that the COVID-19, it's going to be essentially, it may be a generational trauma for many hard-hit communities. It certainly has been a life-changing experience for all of us, but particularly, I think it's going to be for our children. And children who have, you know, perhaps lost a loved one parent or grandparent, for children who have been out of school, but others who have lost jobs who've experienced changes in terms of their housing. And so we have to understand what this means for our health and our health care in the future. ADRIAN: But before I answer the question, I just want to acknowledge the incredible leadership of Dr. Levine throughout the this pandemic, I mean, not only in terms of guiding Pennsylvania, and through the beginning of the pandemic at a time with so much uncertainty for health care workers for the public health for everyday Americans, but also to do so with a lens toward health equity at every step of the way. And that's a thing, you know, Dr. Levine's colleagues in many states also worked on the COVID response, but not all of them prioritized health equity the way that she did. I just want to comment that I think when we're talking about what we need to work for, it's really three areas. So we need behavioral change, clinical change, and policy change. behavioral change means, you know, working within historically excluded and marginalized populations on health promotion to ensure that people who are sometimes not accessing health care information or services can make the best decisions for our bodies in our lives. Clinical changes, you know, there still is a huge challenge where nursing schools, medical school, social work, schools, etc. are not dedicating enough time to education about historically excluded populations, including the health needs of the LGBTQ plus community. And we really need to prioritize clinical education around LGBTQ health needs. Patients jobs are not to teach their doctors, and we should have a society where doctors, nurses, social workers, counselors know enough about LGBT health to provide the care we need. And then policy changes, you know, we're, we're living through systems that were meant to serve the majority population. And that's important. No matter which political party is elected, there are policies that need to be improved to address LGBT health. One of the areas that I know Dr. Levine has done a lot of work in is actually improving data collection, because without data, it's very hard to prove what the challenges are. And so that's one very clear example of policy changes that should not be politicized. They shouldn't be. There's not a Republican or a Democratic way to collect data. It's are you collecting data about the health needs of minority communities, including LGBTQ people? And so I think that the policy change around health data is very critical. SARAH: And Dr. Levine, your office this past spring actually adopted a new policy barring this type of discrimination based on sexual orientation and gender identity from health groups that are federally funded. Can you tell us a little bit more about that? DR. LEVINE: Well, thank you, Adrian, for your very kind comments. And I agree with Adrian completely, addressing health disparities is a priority of the Biden-Harris administration and Secretary Beccera, in our Department of Health and Human Services. And we need to expand our definition of health equity, as I mentioned, to include the LGBTQ plus community, especially those hardest hit and that includes LGBTQ youth, particularly right now trans youth who are confronting many challenges in many states, but also includes LGBTQ seniors. And I would particularly highlight LGBTQ individuals of color, and particularly trans women of color who are at risk not of just discrimination or harassment, but they are at risk of violence and murder. We have not made progress unless we all made progress. So you know, our department is committed to advancing health care for the LGBTQ plus community. Research clearly shows that the transgender giant non-binary gender-nonconforming people disproportionately experience poor health outcomes mentioned violence discrimination. And so you know, the Affordable Care Act, as its goal was to increase access to health care for all of us. That includes the LGBTQ plus community. Among low income, LGBTQ plus community, for example, the uninsured rate has been cut in half since the ACA was first implemented, but gaps exist. And we know that transgender adults are more likely to be uninsured than cisgender people. So we're working to advance that through the ACA. On May 10, 2021, our Office for Civil Rights announced that it was updating its enforcement of Section 1557 of the Affordable Care Act, as well as the title nine prohibition on sex discrimination, that sex discrimination include discrimination on the basis of sexual orientation, and on the basis of gender identity. So it means if you feel you've been discriminated against and health programs, or activities, because of your LGBTQ plus status, you can officially file a complaint. So we are working to expand this throughout the Department of Health and Human Services in terms of all aspects of the ACA. SARAH: And I want to go back to Adrian, can you talk a little bit about what discrimination in healthcare looks like, based on sexual orientation and gender identity? What have you seen that firsthand? What does that look like? And how does that impact why you started Bradbury Sullivan in the first place. ADRIAN: So it's not even always outright discrimination in terms of denying someone care, which is obviously a very clear example of health care bias or discrimination. Sometimes it's, you know, health disparities in real life are not just numbers on spreadsheets, they are people accessing care and in less equitable ways. And what that feels like can mean that people actually fear seeking health care. In Pennsylvania, for example, our state's Patient Safety Authority has actually declared it to be a patient safety violation. If LGBTQ people delay or avoid care because of fear of mistreatment. So the fear of mistreatment, in actual fact, can be just as severe, as severe as actual mistreatment. So that can look like you know, clinicians misgendering, or not using the correct pronouns of their patients, it can look like restrictive intake forms that don't allow a patient to fully identify who they are accurately. You know, on those forums, it can look like it can look like, you know, comments from clinical staff that make patients feel deeply shameful or judged about who they are. For example, we had a client at Bradbury Sullivan LGBT community center, who came in for HIV testing. And after his test, he came into my office and he had $35 in his hand, and he said, I want to donate my copay. And we said, well, that's, that's fine. But you don't have to give us any money. Our services are free. We don't take insurance just it's free, thanks for getting tested. And he said you don't understand. When I went to my doctor, my doctor asked me why I was having sex with so many people. And I felt so ashamed that I walked right out, and I didn't get my test there. And I came here instead. And so that's what health disparities look like in real life are our health care consumers, which is all of us who receive health care, feeling like the care that we might receive isn't going isn't going to be equitable, that we may not be treated fairly. And that's, that's unfortunate, and it's wrong. And again, it's not only harmful for that individual patient, it's harmful for our whole society. Because we'll take HIV testing as an example. One person deciding not to get tested for HIV when they need to, because they're worried about being judged by their clinician means that they don't know their status. And that means that everyone that they interact with, in terms of their sexual partners, doesn't also have an accurate picture of their risk. So it's actually very important that the person getting tested in the first place, feels comfortable getting tested without judgment. And that's just one health issue. You know, we can talk about tobacco, we can talk about cancer screenings, we can talk about, you know, COVID-19 testing, we can talk about so many things, and we can understand that it's a societal challenge, not an individual challenge when we're talking about our public health. SARAH: And so we've certainly been talking about how our healthcare system can do more can do better to promote equitable access to health care and well-being. Can we talk some more about some of the concrete ways that we could accomplish that including what that looks like? Adrian, you mentioned this earlier, but when providers adopt cultural competency and humility in their practice, what does that look like? DR. LEVINE: Well, I think it is critically important, as Adrian was discussing, is that we place cultural competency, you know, front and center. I mean, I think that we have to do that in terms of how we train our healthcare providers. And so, before I entered public service in Pennsylvania, I was in academic medicine at the Penn State College of Medicine and the Penn State Hershey Medical Center. And so we worked to do that at all levels. We work to do that in terms of teaching medical students and teaching residents, you know, residents, physicians in training, that we would end I specifically would teach classes about LGBTQ health and LGBTQ medicine and emphasize some of the specific, specific comments that that Adrian was talking about in terms of understanding LGBTQ people for example, and being culturally competent in terms of addressing LGBTQ plus people and treating them and particularly as he mentioned and being non-judgmental, it is critically important for physicians and nurses and other healthcare professionals to be to be non-judgmental. But my giving a lecture although great, was not sufficient. And so it really needs to be built into the curriculum for for nurses and for doctors, it can't be one lecture that Dr. Rachel Levine gives. It has to it has to be built into the whole curriculum. And that's what they're working on now. SARAH: At an infrastructure level, right? That's what we're talking about the role of health education. And that's how we are training nurses and doctors and all of the providers across the healthcare spectrum. I know in nursing, definitely, there's a huge focus as a major focus of the Future of Nursing 2020-2030 report that we've been covering in recent episodes, to diversify faculty train and more community-based settings. What are some more like infrastructure changes that we might see that that would really change sort of how providers are becoming prepared for practice?

DR. LEVINE: I think you're correct, it needs to be in the infrastructure of curriculums for students as well as for medical professionals. So we do have some impact on that. At the United States Department of Health and Human Services, our Office of Minority Health is certainly dedicated to improving the health of racial and ethnic minorities, working on policies that eliminate disparities, they have a number of different programs. One is called the culturally and linguistically appropriate service and standards. Another is a website called Think Cultural Health, at Think Cultural health.hhs.gov, which contains educational opportunities and resources for healthcare professionals to learn about culturally and linguistically appropriate services. So we need to inculcate this into not only the curriculum for students but also into practice for nurses and doctors and other medical professionals. ADRIAN: And I would just add that in addition to cultural humility, or cultural competency for clinicians of all types, and you know, including nurses, it's also important that we have improved medical education around actually providing the medical care that is unique to LGBTQ patient populations, for example, increasing the number of clinicians who are able to provide, you know, patient education about prep or pre-exposure prophylaxis, preventative medicine for HIV, or increasing the number of, of endocrinologist providing care for the trans patient population. Working on the medical side, in addition to the cultural side, you know, getting patient pronouns correct is very important. Being able to answer the unique medical questions that they might have about their lives is also important. And that's not necessarily learned in a cultural competence program. It is learned through continuing education, that clinicians of all kinds of health care professionals have to do continuing education. And I would encourage, you know, nurses as frontline health care professionals, especially to dedicate some of their continuing ed time to understanding the unique health needs of the LGBTQ patient population. DR. LEVINE: I would agree with that completely. And it needs to be throughout their education process. So for nursing students, and for medical students, it should not be the one lecture or even the one-week block on quote-unquote, LGBTQ medicine, it needs to be to be implemented throughout the medical school education, the preclinical years as well as the clinical years. SARAH: You both have talked about data. And so we'd love to also think about what you know, what kind of research, the role that research can play, what would it have research agenda look like to also help bring these policies forward? What gaps exist, what type of research is needed?

DR. LEVINE: Well, I mean, research is incredibly important. We need to have research in terms of both the health disparities that exist now. And then we need to more research about the outcomes of the policies that we put into place to make sure that they're successful. There are a number of different ways that we do this. NIH has some great research programs about this, either, actually other departments that we don't hear as much about in it, the HHS, that includes arc, and HRSA have great research programs, of course, the CDC, I'm really excited to serve as a member of the White House gender Policy Council. And so we are looking to advance gender equity and equality and domestic and foreign policy, development, and implementation. And so we will be looking for, for data and research to be able to show the outcomes of the measures that we put into place. ADRIAN: And, you know, I think that when we're talking about so separate from federally funded research, but just in general, you know, there's a lot of parts of the LGBTQ community that are under research when it comes to our health. So for example, transgender men are almost always left out of HIV research. For no reason other than the presumption that transgender men aren't at risk for HIV, which is just not true. You know, we need all researchers, whether they're, you know, at the university level, working through private funding, working through public funding, to think about the LGBTQ community broadly, when they're designing their research studies, and to ensure that they're counting us, because when we're not counted, we don't count. And, and it's important to measure LGBTQ health, it's important to count us in demographic data collection. And it's also important to design studies on health challenges that people may not think of as an LGBT health issue. But they are, you know, tobacco is a leading cause of the 12 most common types of cancer and LGBTQ people consume tobacco at about double the rate of the majority population. So tobacco is an LGBT health issue. And tobacco researchers should be including LGBT people in their studies, you know, our health is not only limited to HIV, and, and when we are talking about, you know, cancer screenings, you know, including, you know, including transgender men, non-binary people, lesbian, bisexual women, and studies about mammograms and cervical pap tests, and to actually see what the differences are and why in terms of who's receiving these screenings. And so, when we're talking about federally funded research, that's, that's very important. But it's not only limited to that we need researchers at all levels to prioritize the LGBT community's health. DR. LEVINE: So you know, I agree completely with Adrian and data is so important in general, I mean, one of the challenges the previous administration was a deliberate decision not to collect data on the LGBTQ community and not to collect SOGI, sexual orientation, gender identity data. So we are reversing that on in all aspects of our research. That takes time because you have to redo forms and redo protocols. But we are working on that whether it's NIH research, CDC research or other research in terms of health and health outcomes. And so we absolutely will be including sexual and gender minorities in all of our research programs. ADRIAN: And you know, in Pennsylvania, when Dr. Levine was, was in Pennsylvania leading our Department of Health, we're able to work together on a statewide survey that has now been done three times. It's called the Pennsylvania LGBTQ health needs assessment. And we're actually preparing the 2022 assessment currently, which we're very excited for. It's the most comprehensive state-level, LGBTQ disparity data anywhere in the country. And it's a model for other states to consider as well that, you know, we actually can collect surveillance data on LGBTQ people comprehensively. And, and the result of that data, the results of those data is that we can actually educate clinicians, educate policymakers about what the data is saying and where the where the needs are greatest when we're talking about health issues. SARAH:
 So if all of this is successful, you know, just sort of help us envision this 10 years from now, these trainings are in place this education is in place, what would that look like for practice? Would that look like for the healthcare consumer? ADRIAN: Well, I would say that I don't know if 10 years is realistic, or five years or 20 years, but in our lifetimes, I hope that we can achieve the unmet dream of health equity, which, you know, HHS defines as the attainment of a highest quality of health for all people. I doesn't say All men are all white people are all straight people are all cisgender people. It says it doesn't even say all US citizens. It says all people deserve this, the attainment of the highest quality of health. And I hope that in our lifetimes, that is a dream that can be achieved. Maybe in the 5-10 year ballpark. I hope that we can at least achieve a system where we're accurately measuring the health challenges of historically excluded communities and prioritizing the health needs where the data leads us. DR. LEVINE: Well, I can tell you that it is absolutely It's a priority for our secretary and for health and human services, and really, for the administration to work on that. So it is, apps is one of my most important measures on my portfolio that I'm working on at the Office of the Assistant Secretary, and we're gonna make as much progress as we can, in the time that we have here. ADRIAN: I also dream that this is not something that should be dependent on who is elected at any level of government or who is even in certain positions, that, that the attainment of health equity should be our entire society's goal, because it makes our entire society healthier. And, you know, we went backwards in terms of, of health equity for four years, and now we're going to go forward for a number of years, and that pendulum swings back and forth, you know, depending on who's in office, and that's, that's unfair to the populations who have always been excluded. And we should dream for a system where, you know, LGBTQ people can access health care at all times, no matter what, no matter what happens in an election. SARAH: Well, I really want to thank both of you for your leadership. We have been very lucky to have you both in Pennsylvania, we're okay to have you on loan for a bit, Dr. Levine. But really do you want to thank you both for all of your work and leadership in this area. This has just been an incredible conversation. And just want to give you the opportunity to share any final insights, anything that was going through your mind as we were talking things you really want to make sure our listeners hear and are thinking about going forward. DR. LEVINE: Well, thank you so much. It's been a pleasure to be he re talking about these important topics. It's great to see you, Adrian again, and congratulations and all of your work. So I'm going to end this podcast the way I'm ending all of my interviews now is to highlight the significance of the covid 19 pandemic, on everyone in the United States. It is impacted all of us in so many ways, our health, our families, our schools, our businesses, health care, local, state, and federal government. And our you know, we can see the light at the end of the tunnel. But clearly in terms of the numbers we're seeing now, we are not there yet. And our ticket to getting past the COVID-19 pandemic are through our safe vaccination programs. And so I want to highlight that the vaccinations that we have now are safe, they are effective, and in light of the very dangerous, dangerous Delta variant they are more important for than ever, so please, can please get vaccinated if you have not been vaccinated, the time to get vaccinated is right now. And please help others and your family in your community. Understand the benefits of the vaccination, how safe and effective they are, the more people that are vaccinated, the quicker we do that, the more we can put the pandemic behind us. ADRIAN: I'll just close as well by saying that, you know, without our health, we don't have our lives. And LGBTQ people have fought long and hard for decades, for many decades to achieve legal, legal equality in this country and around the world. You know, President Biden helped to bring marriage equality to our country when he was the vice president. We've had we've had so much progress that has been fought for and the greatest challenge for many LGBTQ people right now, whether we know it or not, are the health challenges that will shorten our lives as a population. And a lot of it's preventable. A lot of it's based on accessing preventative screenings, a lot of it's based on changing our behaviors to stop consuming substances such as tobacco, or as the FDA just recommended to stop, you know, consuming nitrate poppers which are very heavily used among LGBTQ men in particular. We can make these changes, these behavioral changes, these clinical changes, even these policy changes, so that we can live our proud lives longer, and that that should be our goal. SARAH: Well, we've got a roadmap here for how to be healthy, including a very, very concrete recommendation to get your vaccine if you haven't yet. So thank you both again so much for being here. Thank you.

CREDITS

SARAH: Funding for our special Access to Care series comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP and AARP Foundation.

For more about us and our programs, log onto  paactioncoalition.org and nurseledcare.org.  And keep in touch with us on social media @PaAction and @NurseLedCare. 

At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.

I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.

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