Healthcare legislation for older adults in the USA has its origins in the passage of the Medicare legislation enacted in 1965. At that time, President Lyndon Johnson signed the legislation, declaring that no longer will older Americans loose their life savings due to illness (Beschloss 2006). The intent of Medicare was to provide healthcare coverage to persons aged 65 and older and to protect elders from financial risks. However, Medicare does not cover the full financial cost of poor health among elders, requiring many enrollees to pay significant out-of-pocket co-payments and deductibles. In addition, Medicare does not cover a variety of services particularly valuable for those with chronic diseases or a lifelong illness (Kelley et al. 2013). Alternatives to ACA have focused on voucher plans with greater cost sharing; however, such plans would most likely increase, not decrease, out-of-pocket medical expenditures for Medicare recipients (e.g., the bipartisan options for the future, Choices to Strengthen Medicare and Health Security for All, by Senator Ron Wyden of Oregon and Senator Paul Ryan of Wisconsin, www.​budget.​house.​gov/​uploadedfiles/​wydenryan.​pdf). The primary goal of this plan was “to strengthen traditional Medicare by permanently maintaining it as a guaranteed and viable option for all of the nation’s retirees” and simultaneously “expanding choice for seniors by allowing the private sector to compete with Medicare in an effort to offer seniors better quality and more affordable healthcare choice” (p. 1). The plan included the following components: (a) choice, (b) affordability, (c) protecting the guarantee, (d) protecting seniors, (e) protecting the safety net, and (f) lifelong choices. The Wyden–Ryan plan seek to respond to the fast-paced growth of Medicare spending, which is growing more than twice as fast as the economy.

Throughout the twentieth century, healthcare coverage was too expensive and difficult to obtain for many Americans and more so for LGBT persons. Michael Adams, Executive Director of SAGE, in 2009 described the lack of attention of federal policy on LGBT issues in the past eight years (i.e., President George W. Bush’s administration) as a “wasteland” (SAGE Matters 2009, p. 3). Kerry Eleveld, Senior Political Correspondent for The Advocate magazine, added, with the attempt of President Obama and the Congress “to overhaul our health care system and bring more Americans into the fold, older Americans will undoubtedly be a high-priority constituency” (SAGE Matters 2009, p. 5). Moreover, SAGE (2012) asserts that health reform has dramatically improved healthcare coverage for LGBT elders who face health disparities, aggravated by a lifetime of discrimination and higher economic insecurity, in several ways (a) by expanding coverage, (b) strengthening consumer rights and protections, and (c) improving data collection efforts and a host of other benefits.

In general, most people agree that healthcare reform is a step in the right direction in equalizing access to and improving the quality of health care for LGBT persons. The point of division or disagreement is about the extent to which reform is effective beyond access. On the one hand, Baker and Krehely (2012) consider the Affordable Care Act (ACA) as “the most significant and far-reaching reform of America’s health system since the creation of Medicare and Medicaid in the 1960s” (p. 21). Baker and Krehely espouse two major advantages of the ACA to include (a) the introduction of new protections and options for patients in the private health insurance market and (b) expansion of access to more comprehensive benefits and services that focus on improving our nation’s health and lowering healthcare cost by investing in keeping people healthy in the first place. The ACA also includes provisions such as expanding cultural competency in the healthcare workforce to include LGBT issues, improving data collection to better identify and address health disparities, and recognizing the increasing diversity of America’s families (Baker and Krehely 2011). The ACA has implications for LGBT elders from an intersectionality perspective as well: Sexual minorities, elderly, and persons overrepresented with HIV (SAGE 2014).

According to SAGE, for older LGBT persons, poor health represents the cumulative effect of a lifetime of discrimination, and the ACA prevents health insurers from denying coverage or charging higher premiums based on preexisting conditions, or a person’s sexual orientation or gender identity. The significance of this provision is that access to care is expanded for transgender persons and those living with HIV/AIDS, who often face life-threatening discrimination in healthcare coverage. For older persons who already have coverage through Medicare, the ACA has provisions that improve the benefits available through adding free wellness checkups and prevention services. For persons with HIV, the benefits include prescription drug coverage, laboratory services, and chronic disease management. The ACA ended lifetime dollar limits on essential health benefits, cracked down on frivolous cancellations of policies, and made it illegal to arbitrarily cancel health insurance simply because the policyholder got sick (SAGE 2014). See Table 19.2 for ways in which ACA impact on elders.

Chance (2013) acknowledges that the ACA’s reformatory focus on increasing access to care will likely work to remedy some of the discrimination that results in the LGBT community’s disparate access to care. However, Chance believes that the ACA “fails to comprehensively combat the broader LGBT healthcare discrimination because it will do nothing to remedy the stigma that results in lower quality care” (p. 376). Chance identifies the major disadvantages of the ACA, which result in gaps in access to quality medical services that include failure to address the social stigma associated with a patient’s LGBT status and failure to address specific needs of the LGBT community. The recommended reforms include a national legislative and regulatory effort for training competent providers for LGBT patients. Chance recommends “amending the ACA to include provisions requiring applicable agencies to issue rules aimed at increasing implementation and utilization of LGBT-specific cultural competence training provides a convenient vehicle for such reform” (p. 399). In addition, Congress should amend the ACA to require agencies that administer research funding to place a condition on receipt of those funds to treat disadvantaged persons such as those who LGBT (e.g., medical schools). Finally, although not directly related to the ACA, LGBT-specific cultural competence can also be achieved at the state level, stipulating that licensing boards require a certain number of hours of LGBT cultural competence training as a condition of renewed licensure. Chance suggests amending the ACA to address discriminatory attitudes is a better choice for such reform than other avenues.

Those who argue that healthcare reform legislation may have potential negative consequences for seniors suggest several disadvantages. First, health reform will not shore up Medicare’s financing, despite claims to the contrary (The Senior Citizen League [TSCL] www.​seniorsleague.​org). The assurance by lawmakers that healthcare reform would keep the Medicare trust in the black for several additional years is challenged by the Congressional Budget office (CBO), which claims the government is “double counting.” In 2009, a CBO memo stated that “the saving to the health insurance trust would be received by the government only once, thus they cannot be set aside to pay for future Medicare spending and, at the same time, pay for current spending on other parts of the legislation or on other programs” (http://​www.​cbo.​gob/​publications/​25017). Second, as providers experience cuts and go out of business, seniors may have reduced access to medical care (TSCL). To support this notion of the long-term assumption for Medicare and aggregate national health expenditures, reference is made to the Chief Actuary of the government’s Centers for Medicare and Medicaid services who connotes that providers for whom Medicare constitutes is a substantive portion of their business could find it difficult to remain profitable, and without legislation intervention, might end their participation in the program, possibly jeopardizing access to care for beneficiaries (www.​cms.​gov/​Research-Statistics-Data-and-System/​Statistics-Trend-and-reports/​ReportsTrustFund​s/​downloads/​2010TRAlternativ​eScenario.​pdf).

Many LGBT elders are classified as having low socioeconomic status and limited resources and, as such, may be eligible for the Medicaid program. For persons who are eligible for full Medicaid coverage, Medicare healthcare coverage is supplemented by services (e.g., nursing facility care beyond the 100-day limited covered by Medicare, eyeglasses, hearing aids) that are available under their state’s Medicaid program. For persons enrolled in both programs, any services covered by Medicare are paid for by the Medicare program before any payments are made by the Medicaid program because Medicaid is always the payer of last resort (Annual Statistical Supplement 2011). Even so, Medicare does not cover all of a senior’s medical expenses.

Older adults who qualify for the federal government program have several options to purchase additional health insurance called Medicare Advantage plans, which is classified into three basic categories: Private-Fee-for-Service, Health Maintenance Organization (HMO), or Preferred Provider Organization (PPO). According to the Centers for Medicare and Medicaid Services, the most recent addition to the lineup to help manage the health care of senior Americans is the Accountable Care Organizations (ACO). ACO is a collection of healthcare providers who come together and assume responsibility for the care, quality, and cost of healthcare services for a specified group of people. ACO is not an insurance plan. The ACO model is designed to (a) deliver accountable care, (b) emphasize quality of care (a point that Chance (2013) argues is a shortcoming of ACA), (c) coordinate care for patients, and (d) reduce costs by reducing waste (Botek 2015).

The future direction of healthcare reform is uncertain. It is also uncertain whether healthcare reform will regress to something previously known and tried or to something innovative and exploratory. However, several certainties do exist. First, there will continue to be opponents to whatever type of healthcare reform and healthcare legislation is proposed, and second, increases in health care spending along with fiscal pressures created by an aging population and increasing prevalence of debility and chronic conditions make it likely that out-of-pocket expense will continue to rise (Kelley et al. 2013). In addition, an ongoing challenge for healthcare delivery and healthcare reform is related to increasing costs and the ability of the government to continue to fund Medicare and Medicaid in the USA and universal health care in Canada, the ability of individuals to be able to afford health insurance, and the quality of care for LGBT elders. According to Kelley et al., the “average” elder will pay approximately $39,000 in out-of-pocket medical cost during the final five years of life, and a “typical” elder in the top 25 % of medical expenditures will pay about $101,791 in the five years preceding their death (see Research Box 19.1).

As the USA discusses, debates, and determines the next steps for healthcare reform , Barua and Clemens (2014) suggest consulting the Canadian model in terms of what to avoid rather than as a model for reform or replication. In reality, the Canadian healthcare model “is comparatively expensive and imposes enormous costs on Canadians in the form of waiting for services, and limited access to physicians and medical technology” (p. 2). Moreover, evidence indicates that excessive wait times lead to poorer health outcomes and, in some cases, death. Arguably, for many LGBT persons who frequently delay receiving health care, increased wait times further comprise their health outcomes. Conversely, Friedman (2013) argues that a Canadian-style, single-payer health plan would reap huge savings realized from reduced paperwork and negotiated drug prices that will pay for quality coverage for all and at less cost to families and businesses. Friedman advocates for The Expanded & Improved Medicare For All Act (H.R. 676) as progressive taxation to “replace regressive and obsolete funding sources including federal, state, and local government spending on private health insurance for government employees, and state and local government spending on Medicaid and other health programs” (p. 1). See Table 19.3 for ways in which a single-payer program would improve the healthcare system in the USA.