Another year means another LGBTQ Pride season, and another reason to celebrate significant gains in LGBTQ health thanks to the Affordable Care Act (ACA). What are we celebrating in 2017?

For one, more LGBTQ people have health insurance than ever before. Thanks to the ACA, the uninsured rate for low- and middle-income LGBTQ people is at a record low, dropping from a high of 34 percent in 2013 to 22 percent in 2017. Overall, the uninsured rate for this group of LGBTQ people fell by 35 percent since the ACA’s major reforms went into effect. Although we still have a lot of work to do to address LGBTQ health disparities—like higher rates of HIV and tobacco use—access to quality, affordable health insurance has helped our communities begin to close these gaps.

In addition, 2017 was the best year ever for transgender people to enroll in health insurance.  Thanks to a new ACA rule that went into effect in 2017, most private insurers can no longer include plan language that discriminates against transgender people (known as transgender exclusions) or otherwise discriminate against LGBTQ people in health coverage or care. This means that new insurance plans, while still far from perfect, are better than ever: our analysis in December 2016 found that the vast majority of silver marketplace plans in 16 states had removed transgender exclusions. Even better, nearly 20 percent of plans had language indicating that all or some medically necessary transition-related care would be covered. Although there is still more work ahead of us to improve health care for transgender people, this—plus the fact that 14 states and DC now affirmatively cover transition-related care in their Medicaid programs—shows significant progress.

Despite these gains, LGBTQ health is under attack. Instead of building on the progress the ACA made, members of Congress and the Trump administration want to take health care from millions, including an estimated 1 million LGBTQ Americans, and gut essential nondiscrimination protections. The American Health Care Act—passed by the House and currently under consideration in the Senate—would strip insurance from 23 million Americans, hike premiums by 20 percent next year, and cut $834 billion from Medicaid, all while eliminating protections for people with preexisting conditions. These are just some of the changes that Congress is considering to give tax breaks to the wealthy while cutting billions of dollars from programs that low- and middle-income LGBTQ families rely on.

At the same time, the Trump administration has threatened to roll back parts of Section 1557 of the ACA, which bans sex discrimination in health care programs that receive federal funding and is critical to ensuring that LGBTQ people are treated respectfully when accessing coverage and care. Because Section 1557 is not subject to the budget reconciliation process, Republicans in Congress cannot repeal this part of the ACA, so Section 1557 is likely to remain in place at least for the near future.

However, parts of the Section 1557 regulation—a rule issued by the Obama administration that was finalized in May 2016—have been challenged in federal court. The plaintiffs in the litigation, Franciscan Alliance v. Price, challenged the Obama administration’s interpretation that the ACA’s ban on sex discrimination prohibits discrimination based on sex stereotyping, including gender identity. Judge Reed O’Connor—the same judge who blocked the Obama administration’s efforts to protect transgender students—agreed with the plaintiffs and issued a nationwide preliminary injunction on December 31, 2016.

Although a setback, this injunction is temporary and applies only to the Office for Civil Rights at the U.S. Department of Health and Human Services (HHS). Under this ruling, HHS is barred from enforcing Section 1557’s protections for transgender people. However, the Section 1557 rule itself remains firmly in place. This means that covered entities, such as hospitals and state Medicaid programs, must continue to comply with Section 1557, and LGBTQ people continue to be protected from discrimination in health insurance and health care. We can’t emphasize this enough: LGBTQ people should never face discrimination and, if you do, you have rights and should contact Out2Enroll or a legal organization for help.

Advocates should also be aware that HHS has asked Judge O’Connor to stay the litigation to allow the Office for Civil Rights to reconsider the Section 1557 rule. We are currently awaiting his decision on this issue, but advocates should be prepared to educate and activate your networks about the importance of Section 1557 if and when the rule is reopened.

Thank you for everything you’re doing this Pride season—from spreading the word about enrollment at Pride festivals, to calling members of Congress to ask them to protect the ACA—and for your ongoing commitment to LGBTQ health. Out2Enroll and Community Catalyst will continue to keep you posted on new developments and what you can do to promote LGBTQ health equity.

Katie Keith is a member of the Steering Committee at Out2Enroll

If you arrived at an emergency room or urgent care clinic with a painful infection of your finger that is causing you to miss work and otherwise interfere with daily living – would they give you pain relievers and send you on your way? Often, that is exactly want happens for toothaches.

Oral health is vital to overall health, yet too many people are not getting the care they need. In her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, journalist Mary Otto chronicles the fragments of oral health care. The settings vary: the shadows of Baltimore MD’s own iconoclastic University of Maryland School of Dentistry, the first academic institution to award a dental degree, to far-flung Appalachian outposts. The muckraking journalism drives the text – following the “who, what, when, where, and why” behind the stories of a budding beauty queen and a despondent mom with young sons who need a tooth pulled. While the national conversation on affordable, accessible and equitable health care spurts forward, Otto’s point of entry – the medical neglect of a young man who suffers a deadly toothache – remains unreconciled.

Oral health issues are ubiquitous. Dentists are not.  In fact, “dental deserts,” areas with no oral health services, permeate every state. Adding to the problem is that no one can tell private dentists who they have to treat, or what they can charge for procedures. This contributes to an excess of practices that do not accept Medicaid while simultaneously promoting revenue-generating “cosmetic dentistry,” or “perfect smile” treatments for patients who can afford them (often through payment plans arranged through the office directly, as Otto points out).

This is why health care advocates keep pushing for licensed mid-level providers – “dental therapists” – who could increase access to care to the numerous dental deserts across the country. Analogous to physician assistants, dental therapists are trained in specific dental prevention and treatment procedures – like cleaning teeth or pulling an abscessed tooth. In 2000, then Surgeon General David Satcher MD, PhD issued the first-ever oral health report for the U.S., calling out the urgent need for mid-level dental providers. Since then, state-based legislation to carve out a “dental therapist” professional category has crawled up the health care reform docket. There are now four states that allow dentists to hire dental therapists – Alaska, Minnesota, Vermont and Washington, which recently approved dental therapist utilization on tribal lands of American Indians (who see the societal and economic impact of the lack of dental care). Twelve more are actively pursuing the creation of a dental therapist licensure category.  But in many states, legislation has been blocked or watered down by the professional dental societies.

The Forsyth Institute joins with Community Catalyst and other advocates pushing for dental therapist legislation across the country and in our home state of Massachusetts, to reach children and their adult caretakers, for whom an ounce of prevention would relieve a lifetime of pain and chronic disease. Each year, more than 13 million school hours are lost due to dental disease. The burden of dental decay is heaviest among children of minorities and those living in poverty. Chronic pain that dental therapists could help. 

It’s time to stop allowing the dental industry to practice in their own best interest instead of the best interest of their patients. We need to push to ensure that we are addressing the vast inequities the vulnerable and underserved face when attempting to access oral health care. Dental therapists are one of the answers.

Diane MacDonald is the chief operating officer and interim president and CEO at the Forsyth Institute. She is also a member of the Community Catalyst Board of Directors.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

As health advocates work tirelessly to defend the Affordable Care Act in a wildly contentious partisan climate, we simultaneously find bipartisan efforts to combat the opioid crisis. But today’s overdose problem is not the first time our country has faced a devastating drug crisis—and even though drug overdose death rates now exceed those due to firearms and cars, overdose deaths have been increasing since 1980. So why the unified response now? Many outlets are rightly pointing out that the social and political reactions we see in the current opioid crisis differ dramatically from the criminalized approaches of the 1980s “War on Drugs.”  

It’s important to look at how structural racism has contributed to the opioid crisis, and recognize that structural racism has also created the public motivation to try and do something about it.

What’s Different about the Opioid Crisis?

In short, the current opioid crisis has a different face.

The 1980s drug crisis was the “crack epidemic” and stereotypically portrayed as a phenomenon of “the violent black inner-city,” focusing on criminally dangerous drug addicts. Media coverage at the time shamed black mothers with addiction in particular, referencing “a time bomb in cocaine babies” and the “bio-underclass.” Crack was “reaching out to destroy the quality of life, and life itself, at all levels of American society.” In reality, the harm caused by the crack epidemic was not as severe as the media sensationalized. However, the resulting punitive approaches of the “War on Drugs” with harsh sentencing and mandatory minimums disproportionately affected communities of color with devastating effects.

Today, we're shown a different face in the opioid crisis – a white one. Since 2001, the opioid overdose death rate among non-Hispanic whites has been higher than that of non-Hispanic blacks, and has sharply increased in recent years. With this new face comes a new response: rather than demonizing substance use as criminal behavior, our nation emphasizes treatment and public health interventions.

Opioid Overdose Deaths by Race/Ethnicity, Age-adjusted Rates Per 100,000 Population

Timeframe: 1999 – 2015

Source: Opioid Overdose Deaths by Race/Ethnicity, obtained from kff.org

Why is the opioid crisis disproportionately affecting whites?

Non-Hispanic whites make up more than 80-percent of opioid overdose deaths in the United States, and structural racism plays an important role in explaining this. A major driver of the current crisis is over-prescription of opioid pain relievers. Research shows communities of color have poorer health insurance coverage, less access to care, and get lower quality treatment than whites. Whites therefore may be more at risk of opioid overdose since they – and likely their family and friends – are more apt to be engaged in the health system to begin with, and thus more likely to obtain prescription pain medication.

On the whole, racist stereotypes lead to different pain treatments for black and white patients. Whether it’s the untrue assumptions that a black patient’s pain threshold is higher than their white counterpart or that a black patient is more likely to divert prescription pain pills to the illicit drug market, there’s a structural racism in the way pain is managed in this country. 

How are the social and political responses different?

Studies show we are more likely to empathize with people who look like "us,” and policy-makers are more likely to be white. When law enforcement, elected officials and others in positions of power see themselves and their family members in opioid “victims,” they are more compelled to act with some compassion.

It’s why the punitive response to the crack epidemic has shifted to focus on treatment. Instead of criminals and selfish monsters, those misusing opioids are victims who need help.

One former narcotics officer described his new outlook:

“The way I look at addiction now is completely different…I can’t tell you what changed inside of me, but these are people and they have a purpose in life and we can’t as law enforcement look at them any other way…They need help.”

Substance use disorders have been affecting diverse communities for decades, but we are now focusing on the opioid crisis as a window of opportunity for shifting important public health policy. And in the words of Ekow Yankah, Law Professor at Yeshiva University:

“It is hard to describe the bittersweet sting that many African-Americans feel witnessing this national embrace of addicts. It is heartening to see the eclipse of the generations-long failed war on drugs. But black Americans are also knowingly weary and embittered by the absence of such enlightened thinking when those in our own families were similarly wounded. When the face of addiction had dark skin, this nation’s police did not see sons and daughters, sister and brothers. They saw “brothas,” young thugs to be locked up, rather than “people with a purpose in life.”

So, what do we do now?

We should not ignore the very real devastation of the current opioid crisis. Nor is the answer to structure health advocacy efforts solely on opioids, perpetuating the notion that because the problem has a “white face,” more people will care. That will only promote the structural racism we already see in our social, legal, political and health systems.

Instead, we need to employ a health equity approach by promoting policies that will equally benefit diverse populations: communities of color and white communities, rural and urban, young and old, wealthy and disadvantaged. We need to use a strategy that says “We don’t have to wait until a problem has a white face to answer with humanity.” This means calling out specific injustices when we encounter them, including Attorney General Jeff Sessions’ return to punitive policies for drug crimes. It also means building diverse coalitions to promote our policy issues.

Specific to substance use disorders policy, this also means advocating for treatment and prevention policies that refer to all substance use, and not opioids alone. To do anything else will continue to elevate the health of white people over communities of color.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

Our advocacy around race and health requires us to address racism as a cause of poor health, recognizing that without addressing this root cause, attempts at solving health inequities will continuously fall short. However, in order to bring full awareness to the consequences of racism on health outcomes, we must take a step even further back, and address the ways structural racism is embedded in health policy and health advocacy. When the foundations for the health advocacy strategies that shape our policies are flawed, we build structures that benefit some people above others. We then spend the rest of our time and energy trying to find resources for how it can benefit everyone that was left out, repeatedly finding that these systems do not work for people they weren’t originally built for. In doing health advocacy work, I am often taken back to childhood memories of translating important medical information and conversations between doctors and my mother, both of them speaking a different language in more ways than one, and even then I understood that the health care system was just one more place where we, a family of immigrants, didn’t belong. The system wasn’t made for us, and therefore very seldom did it meet our needs.

The story of health policy in the U.S. continues to be one of racial discrimination in coverage access and health care delivery, and advocates often find themselves fighting the same battle on many fronts. Even when health policy shifts towards racial inclusion we see that the impetus for the shift is often tied to the sudden realization that the issue also impacts whites. Take for example, conservative white America’s newfound support for the Affordable Care Act- Judy Lubin, a sociologist and adjunct professor at Howard University in an interview with CNN described the recent shift: “Americans now realize Obamacare helps millions of working class whites and that it's not as once portrayed by conservatives a form of welfare pushed by the first black president to help people of color.” As health policy advocates working tirelessly to preserve the ACA and the coverage it provides millions of Americans, we must find ways to showcase the new voices of conservative whites without drowning out the ones of people of color whose sustained support helped pass and implement the law and whose lives will be disproportionately affected by its loss.

One way health policy advocates can stand against structural racism is by continuing to center our work on health equity, especially while in campaign mode. It is in these moments of chaos that we must ensure that the need for a “win” does not come at the expense of sidelining voices of color. The win that comes at the expense of marginalized people does not effectively support those people in the end. Instead, it guarantees that we will get less than what we need, and we will have compromised our values to get there. Take for example the current campaign to save the ACA, one where we recognize that those most likely to be hurt by a repeal are the voices least likely to have any sway with most Republican members of Congress. However, if we allow policy advocacy and negotiations to meet the standard of who is most likely to be heard, we fail all of the people who already feel left out of the process.

Equitable health advocacy requires that we build coalitions and the collective power necessary to ensure health policies serve diverse populations. Strategic power building elevates the voices of those most likely to be heard as a tool for bringing into the conversation those historically silenced. When equitable health advocacy is used to promote policies not on behalf of but rather in partnership with communities of color, we reset the expectation of who advocacy works for. This is the only way we can avoid elevating the plight of white people in hopes that there will be leftover resources for people of color. As a health advocate, and a person of color, I understand that through my proposed strategy approach of all of us - not just some of us. When we lose, we all lose. However any strategy that doesn’t see people of color as essential to the fight, also guarantees that even when there is a win - people of color continue to lose.

Only through the intentional inclusion of diverse communities can we continue to take active steps to interrupt and dismantle systemic racism. By working with government agencies across sectors, health care providers and  community leaders we can identify opportunities for equitable health policies and create innovative strategies for addressing disparities as well as the continual investment in the health and success of communities where racism actively disrupts progress.