• Emily Lupton Lupez, Steffie Woolhandler, David U Himmelstein, Samuel Dickman, Elizabeth Schrier, Lenore S Azaroff, Chris Cai, and Danny McCormick.
• Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA. elupez1020@gmail.com.
• J Gen Intern Med. 2025 Jan 2.

BackgroundMillions of Americans have medical debt and/or defer care due to cost. Few studies have examined the association of such health-related financial problems with sexual orientation or gender identity, and whether state-level policies protecting sexual and gender minority (SGM) people affect disparities in such problems.ObjectiveTo examine the relationships between SGM status, state-level SGM protections, and health-related financial problems.DesignCross-sectional analysis.ParticipantsNationally-representative sample of U.S. adults in the 2021 National Financial Capability Study.Main MeasuresPrevalence of medical debt and/or deferred care; adjusted odds ratios (aORs) by SGM status and residence in a state with fewer SGM protections.Key ResultsOf 25,170 survey respondents, 3.7% were gay/bisexual men, 4.3% lesbian/bisexual women, and 0.6% transgender people. Among lesbian/bisexual women, 39.4% had medical debt, the highest proportion of any group. Accounting for sociodemographic and personal-financial factors, women and all lesbian/gay/bisexual persons (vs. straight men) more often experienced medical debt (aOR [95% CI]: straight women 1.28 [1.16, 1.41], gay/bisexual men 1.55 [1.23, 1.94], lesbian/bisexual women 1.80 [1.50, 2.10]) or deferred care (e.g., 1.80 [1.51, 2.16] for lesbian/bisexual women). Transgender people vs. cisgender men were more likely to defer care (aOR = 2.58 [1.54, 4.30]). Living in a state with fewer SGM protections was associated with higher rates of health-related financial problems for most groups, especially cisgender women and lesbian/bisexual women.ConclusionsLesbian/gay/bisexual, female, and transgender adults experience more health-related financial problems, especially in states lacking SGM protections, underlining the importance of universal, comprehensive insurance coverage (including for services unique to SGM people), ending bans on gender-affirming care, and closing the male-female pay gap.© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.

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