"We are not going away. We won't die secret deaths anymore. The world only spins forward. We will be citizens. The time has come. Bye now. You are fabulous creatures, each and every one. And I bless you: More Life. The Great Work Begins."
--Tony Kushner, Angels in America
In the last half-century, LGBT people have experienced a widening circle of acceptance. With each step of the circle outwards, more Americans got to know their LGBT friends, family and neighbors for who they are, and together we became more aware of our commonality than our otherness. Knowing an LGBT person is considered a big factor in acceptance, and acceptance grew to the point that support for marriage equality went from 37% in 2003 to 61% in 2015, with a whopping 78% of Americans under age 30 supporting marriage equality. What will naturally follow the landmark Supreme Court decision of June 26 will be many regulatory and policy changes in both government and the private sector, ranging from joint tax filings, to health insurance coverage, to eligibility for valuable spousal Social Security benefits that had always been beyond reach for same-sex couples. We'll also see an evolution in the rules for child custody, child support, shared property and alimony after divorce.
Nevertheless, we have learned the hard way that rights on paper do not always easily translate into rights in reality. In the United States, we are currently witnessing racial hatred manifested by what some see as the equivalent of domestic terrorism - carried out not only by hateful individuals but also by officers of the law. More than 60 years after Brown v. Board of Education, these current events prompt many of my concerns for the future of LGBT acceptance in America. Will acceptance achieved in the highest court now fan the winds of ill will in the next election cycle? Look no further than the words of many Presidential candidates. Their rhetoric in the wake of the Supreme Court's marriage equality decision is a scary reminder of how mean-spirited some people can be.
My own particular interests are in the health care sector, where politics should have less influence - yet the partisan fight over small words in the Affordable Care Act (ACA) has led to significant amounts of time, energy and money being spent on attempts to weaken this law. These resources would have been better spent on efforts to improve implementation of policies that really make a difference for many in need of care. This is an LGBT issue, too. We know that LGBT people experience disparities in health care, often as a result of stigma and discrimination experienced in the process of seeking care. This has been well-documented in a 2011 report on the health of LGBT people by the Institute of Medicine:
- LGBT youth are more likely to attempt suicide or be homeless.
- Men who have sex with men, particularly young black gay and bisexual men, experience the highest rate of new HIV cases - largely in the South.
- Lesbians receive cancer screening less often than heterosexual women.
- Transgender women have the highest prevalence of HIV of all American adults.
- Transgender people experience widespread difficulty accessing the care they need.
I did my medical training in a hospital that prided itself in serving all with one class of care. The CEO even instituted a rule in the early 1980s that everyone who worked there, both clinicians and non-clinicians, had a duty to care for people with HIV and AIDS. Some who did not agree did leave their jobs. This strong stance for equality is still needed today. We need to continue our work with health care organizations across the country to ensure that staff are trained to care for LGBT people. This means focusing on communication and inclusiveness, as well as key elements of prevention and treatment where providers' lack of knowledge has been shown to lead to sub-optimal care.
It is somewhat reassuring that the National Journal and others are reporting that many governors are rethinking Medicaid expansion in their states, following the Supreme Court's pro-ACA decision in King v. Burwell. Many LGBT people live in states without new eligibility for Medicaid. When Medicaid ineligibility is combined with marriage inequality, LGBT people are hard-pressed to find needed care that is affirmative and inclusive. We should celebrate these two Supreme Court rulings and their positive impact on American life, but we must remember that our work remains cut out for us to ensure that we are a nation that provides equitable and high-quality care to all.