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Decades of Unique Lesbian, Gay, Bisexual and Transgender Health Care May Face Challenges as Funding Evolves

November 2005

Seven Centers at a Glance >>
Comparisons of:
  • Callen-Lorde
  • L.A. Gay & Lesbian Center
  • Howard Brown
  • Montrose
  • Chase-Brexton
  • Fenway
  • Whitman Walker
Picture the early 1970s: In America, the sexual revolution had begun. The nation's soul-searching on account of race had been followed quickly by women's liberation and the nascent gay rights movement. Civil rights, the pill and legalized abortion overcame long-held taboos and granted Americans new liberty over their own bodies. And a new consensus held that no one should be denied access to healthcare. Medicare and Medicaid were less than a decade old, and the idea of creating free clinics was becoming a movement.

In those idealistic times, humble operations began to crop up in American cities, offering low-cost or free health services to the gay population. The first few were started in Boston, Los Angeles and New York City in 1971, and then in Washington, D.C., two years later, followed over the next few years by clinics in Chicago, Baltimore and Houston. Although there are many smaller such clinics, seven have advanced to become major health centers with a collective annual budget of more than $100 million. They specialize in meeting the health needs of lesbian, gay, bisexual and transgendered people (known collectively as LGBT) who may be poor or underinsured.

Because these seven LGBT health centers initially served a largely gay population in the 1970s and early 1980s, they were quickly exposed to the emerging AIDS epidemic. Now, 30 years after their founding, they annually treat more than 10,000 largely low-income, uninsured or underinsured HIV-positive people. They also provide HIV prevention and testing services for another 40,000 people. In addition, they help conduct more than 100 HIV research studies.

The services the seven LGBT health centers provide for HIV-positive people have become highly evolved. They include primary care, case management, dental services, physical therapy and substance abuse treatment (for details, look at the accompanying chart). Interestingly, however, the vast majority of the patients served by them today are not HIV positive. Many patients -- 40 percent -- do not even identify as lesbian, gay, bisexual or transgender.

How did these seven clinics manage to make their HIV care so exceptional? And what makes their services so attractive even to patients without HIV, as well as to straight patients?

Cutting-Edge HIV Talent and Research

At a time when much of the country barely knew what HIV was, the seven responded quickly to the new health needs, and then stayed at the leading edge of health care by attracting and collaborating with leaders in the fields of HIV medicine and research.

"Fenway [began] studies of HIV in the early 1980s," recounts Stephen Boswell, M.D., President of Boston's Fenway Community Health. "Then we moved logically into studies of HIV transmission and prevention, and therapeutic and preventive vaccine trials, behavioral studies, and microbicide studies."

"Fenway's collaborations with Harvard investigators provided some of the first descriptions of HIV in semen, the immunology of long-term nonprogressors, and more recently, studies of the integration of HIV prevention in the care setting of people living with HIV," Dr. Boswell added. Much published research has resulted, burnishing Fenway's reputation as a key center for studying HIV.

Like Fenway, the other major LGBT health centers are based in cities where top medical talent can be found, and where outstanding teaching hospitals are located. The centers continue to attract medical talent, and with it, research collaborations with universities such as Yale, Harvard, and the Universities of California, Texas, Illinois and Minnesota. Three of the centers -- the Los Angeles Gay & Lesbian Center, the Whitman Walker Clinic in Washington, D.C., and the Montrose Clinic in Houston, Texas -- in fact specialize in primary care for people with HIV.

Economic and Cultural Advantages

Top specialists and HIV research are not the only qualities that draw patients to the LGBT health centers, however. Two other factors play a significant role. The first is pure economics.

"For uninsured people, the health centers are lifesavers," says Kenneth Ruby III, Director of Case Management and Outreach at Baltimore's Chase-Brexton Health Services. "They get medical treatment they may not otherwise access, plus all the ancillary services like help with getting insurance for medications, or even help paying for them."

Houston's Montrose Clinic has played a vital role after Hurricane Katrina by caring for evacuees with HIV (though care is not confined to people with HIV or to LGBT people). "We've seen approximately 300 and the number increases daily," states Katy Caldwell, Montrose's executive director. Montrose says it has been able to fund its care of this sudden rush of new patients with donations from individuals and foundations.

The second big draw for the LGBT health centers is what is known in medical circles as "cultural competence." Cultural competence entails a combination of expertise and sensitivity with regard to specific communities.

"Think of the lesbian who doesn't have sex with men and is always asked about that or screened for things she doesn't need," says Ruby, "[or] the male-to-female transgender client who might get referred for women's services, but not need them." Because of their heightened cultural awareness, the centers have developed health services in which these problems do not arise, making the overall healthcare experience much more positive for patients.

Thanks also to this expertise, the centers have the ability to address issues -- and conduct targeted health interventions -- that otherwise might not be possible. For example, at New York City's Callen-Lorde Community Health Center, "We routinely screen men who are sexually active for syphilis, and so are the single largest syphilis treatment provider in NYC," says Jay Laudato, Callen-Lorde's executive director. "Most of these patients were in secondary stage syphilis and had missed the symptoms of primary infection."

Besides expertise, an added level of sensitivity and understanding means that these seven health centers are "a safe place to be yourself," says Ruby. LGBT people can be "open and honest about personal information like who [they] have sex with -- nothing is going to shock us," he adds.

This contrasts with the great number of ordinary doctor-patient encounters elsewhere. Often, Laudato says, "doctors are reluctant to raise issues of sexually transmitted infections, substance use or mental health," and in turn, LGBT people are "especially fearful when dealing with medical issues that may be related to sexuality."

Given the LGBT health centers' welcoming approach to their patients, it was only a matter of time before their appeal began to extend well beyond the LGBT population. "Sensitivity and non-judgment towards LGBT people extends to all persons who are different," says Ruby. "I would bet that anyone can think of a time when they've met with a healthcare provider who didn't take the time with them they would have liked, made incorrect assumptions, or was downright sexist, racist, etc. Everyone wants a healthcare provider who truly listens and doesn't judge."

Echoing that sentiment, Laudato says, "Our gynecology program is a big draw for straight women who find the practice more sensitive. One of my favorite stories is of a young gay person who utilized our adolescent clinic and then on the following day brought back his mother and sister for care."

With Ryan White in Flux, Centers Express Concern

Top-flight medical care, cutting-edge research and cultural competency may have dramatically enhanced the scope of the services that these seven health centers have provided over the years, but their significant roots in HIV mean that a significant portion of their funding relates to HIV. Nearly a third of the seven centers' collective operating budgets come from federal funds, largely through the Ryan White CARE Act (though percentages vary from center to center). Some centers are very worried about future funding.

The Ryan White CARE Act provides about $2 billion annually in federal funding to organizations that provide medications, medical treatment and care for approximately 500,000 people with HIV in the United States, as well as to organizations that provide HIV prevention services. Since it became law in 1990, the Act has become a linchpin for HIV service providers throughout the country; many organizations rely on the funds for their survival.

The Ryan White CARE Act expired on Sept. 30 and Congress is currently in the process of reauthorizing the Act, as it does every five years. In an era of budget cuts and shifting priorities, many recipients of Ryan White funds -- including the seven centers -- are concerned. They say that depending on the changes Congress makes to the Act, some of the services they provide for people with HIV could be in jeopardy.

"We could be hit with a major reduction," says Jim Key, Chief Public Affairs Officer of the L.A. Gay & Lesbian Center. Key's concerns center around how the Ryan White CARE Act allocates money to metropolitan areas throughout the country. Unless the Act's timeline for reallocating funds to metropolitan areas is modified, the Los Angeles metropolitan area, as defined by the Act, "is looking at direct cuts, which impact our ability to provide services."

In calling for increased funding of HIV medications under the Ryan White CARE Act, Key notes that the L.A. Gay & Lesbian Center alone spends $12.5 million in such funds annually to pay for 66 percent of all the drugs that it distributes to people with HIV.

Chip Lewis, Media Relations Manager at D.C.'s Whitman Walker Clinic, which had around $2.5 million in cuts in 2005 and had to close its Takoma Park, Md., facility, warns of other cuts.

The focus of President Bush's plan for the Act's future, on so-called "core services," "may endanger our food bank and legal services," Lewis says. He is also concerned that Bush's "core services," which still have not been defined by the President or by Congress, need to include "psychological counseling, case management and addiction treatment services." Lewis further warns that the Ryan White funding formulas under consideration could penalize places like D.C., which have strong Medicaid programs or local medical coverage for the poor.

But not all centers face the same challenges. At Montrose, the center with the smallest annual budget, "We are not in danger of losing services unless there are drastic funding cuts in the appropriation, as our services all fall in the area of 'core services,'" says Caldwell.

Despite the looming uncertainty of the Ryan White CARE Act's reauthorization, the centers remain as dedicated as they have ever been to providing outstanding care to those in need -- be they LGBT or straight, HIV positive or HIV negative.

Deliberations are expected in Congress on reauthorizing the Ryan White CARE Act before the end of the year. Interested readers can click here to find out more about the reauthorization process.

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This article was provided by TheBody.
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