Structural
State-level LGBTQ-related policy trajectories (2015-2022) and health and healthcare access outcomes (2023) in the United States: A sequence and cluster analysis approach Dougie Zubizarreta* Dougie Zubizarreta Ariel L. Beccia Anusha M. Vable Allegra R. Gordon S. Bryn Austin
Background: Discriminatory policies are a root cause of LGBTQ health inequities. Over the past decade, there has been a cascade of legislative attacks targeting LGBTQ people’s rights, yet limited research has characterized state-level LGBTQ-related policy trajectories over time and examined their implications for population health.
Methods: Using LGBTQ-related policy data from the Movement Advancement Project, we constructed state-level policy trajectories for 2015-2022. We conducted a sequence analysis to quantify differences between policy trajectories and cluster analysis to group similar trajectories. We fit survey-weighted multilevel logistic models to estimate associations between policy trajectory clusters and individual-level health and healthcare access outcomes using data from the 2023 Behavioral Risk Factor Surveillance System. Predicted probabilities for each health outcome by policy trajectory cluster and LGBTQ status (LGBTQ, cisheterosexual (CH)) were obtained via marginal standardization.
Results: From 37 unique trajectories, we identified 5 trajectory clusters: “consistently predominantly discriminatory (C1)”, “consistently fairly discriminatory”, “fairly discriminatory change to moderate”, “moderate change to fairly protective,” and “fairly protective change to predominantly protective (C5).” For most outcomes, health was worse in states with consistently discriminatory policies compared to states with increasingly protective policies, with disproportionate impacts for LGBTQ adults. We observed inequities between LGBTQ and CH adults within policy trajectories, and inequities within LGBTQ status groups across trajectories. For example, predicted probabilities of avoiding care due to cost ranged from 24% in C1 states to 11% in C5 states among LGBTQ adults, and from 10% in C1 states to 7% in C5 states among CH adults.
Conclusions: Findings underscore the need to abolish harmful policies and enact protective policies to mitigate health inequities.
