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Integrated Health Partnerships—Minnesota’s Medicaid Accountable Care Organization Model
August 16, 2024:Minnesota's Integrated Health Partnerships (IHPs) have pioneered a new approach to implementing accountable care organizations (ACOs) for the Medicaid population. Initially launched in 2013 by the Minnesota Department of Human Services (DHS), these partnerships are voluntary agreements between health provider groups and DHS. Health provider groups partner directly with DHS in multi-year contracts to both improve the quality of and reduce the total cost of care for specified patient populations using a shared savings/shared risk financing model.
When IHPs were first established in Minnesota, there were six provider groups participating. A little more than 10 years later, the number of IHPs in Minnesota has more than tripled, with 25 total partnerships covering more than 505,000 beneficiaries, as of July 2024.
DHS released the 2025 Request for Proposals (RFPs) (which recently closed) hoping to expand the program to more interested organizations and to allow current organizations to continue their partnership with the agency.
In order to better understand potential expansions and changes that may be implemented through Minnesota’s IHPs, we must first understand the foundation, function, and purpose of these partnerships.
In this blog, SHADAC staff will explore:
- What is the purpose of an Accountable Care Organization (ACO)?
- How do IHPs relate to ACOs?
- How have IHPs been established in Minnesota and how have they evolved?
- How can IHPs advance health equity for included populations?
- What are some future considerations that could help in better understanding the effect of IHPs?
Keep reading to start learning about the IHP program and how it impacts communities in Minnesota.
ACOs in Medicaid
Accountable Care Organizations (ACOs) are groups of health care providers that agree to take financial responsibility for the quality and cost of care they deliver to a defined patient population. There are national, state, and regional ACO models, and they may support multiple insured populations, i.e., Medicare, Medicaid, commercial, and self-insured.
ACOs often operate alongside Managed Care Organizations (MCOs), offering additional avenues for health care reform and focusing increasingly on advancing health equity. ACOs are a pivotal tool in promoting access to care, investing in population health, and addressing social determinants of health that affect health equity.
Since the enactment of the Affordable Care Act (ACA) in 2010, the Center for Medicare and Medicaid Innovation (CMMI) has supported state initiatives like Minnesota's State Innovation Model (SIM) to test and expand ACO models within Medicaid, and Medicaid-specific ACOs have now been established in nearly a dozen states.*
These programs vary by state in terms of delivery system reform, payment expectations, and in the authorities needed to administer them, but all such Medicaid ACO alternative payment models (APMs) are standardized through classification under Categories 2, 3, and 4 of the Health Care Payment – Learning Access Network (HCP-LAN) APM framework.
IHPs are Minnesota’s Medicaid ACO model. In 2008, the Health Reform Law of Minnesota included recommendations for statewide quality reporting, payments for coordinated care services provided in health care homes (HCHs), and encouragement to participate in bundled payment demonstrations. The law was then amended in 2011 to require DHS to develop a program to “test alternative and innovative health care delivery systems, including ACOs that provide services to a specified patient population for an agreed-upon total cost of care or risk/gain sharing payment arrangement”, leading to the creation of IHPs.
In 2017, SHADAC had the opportunity to conduct an evaluation of early Minnesota IHP implementation as part of Minnesota’s SIM cooperative agreement with CMMI, which documented IHP expansion and evolution, helpful data analytics, and importance of ongoing monitoring of the effects of the IHP program on health care utilization, cost, and quality.
Minnesota's Integrated Health Partnerships Today
As noted earlier, Minnesota’s IHP program began over 10 years ago in 2013. In 2018, the program was updated with various enhancements and changes in order to place a stronger focus and effort on health equity, enhance the risk arrangement incentives, and provide a population-based payment. This led to the implementation of a new overall IHP model (Integrated Health Partnerships 2.0) with two possible tracks for Minnesota IHPs to operate under (see figure below). These two distinct organizational design tracks are tailored to both provider capabilities and population needs.
For full details and requirement on IHP design tracks, please reference the Minnesota Department of Human Services 2025 Request for Proposals for IHP Program
On top of improving care quality and reducing the total cost of care, IHPs on both tracks are also required to design interventions that address specific health disparities across their target population. IHPs in both tracks receive a quarterly risk-adjusted population-based payment (PBP) which is intended to contribute to care coordination and other investments for the population served. IHPs are also assessed based on quality, utilization, and health equity measures. This population-based payment is flexible, adjusting to reflect changing numbers of the included population specified by the IHP’s intervention plan, as well as changing risk factors due to medical and social complexities in the population makeup.**
IHPs are measured through quality and data metrics (e.g., comparing percent change between performance years), as well as a calculation of standards across five domains for those in the shared-risk model - Quality Core Set, Care for Children and Adolescents, Quality Improvement, Closing Gaps, and Equitable Care - a process which is described in further detail in the following section.
Ultimately, IHPs have proven quite successful in Minnesota, with significant savings and quality improvements. Since their inception, IHPs have yielded nearly $546 million in total savings through 2022.
Emphasis on Advancing Health Equity
In response to evolving health care needs and feedback suggesting that the timing was right to build on prior successes of the original IHP program, DHS introduced an improved program, IHP 2.0, enhancing its focus on health equity. The IHP 2.0 program, included modifications to allow the program to more directly address social determinants of health (SDOH) and incentivize partners to reduce racial, geographical, and/or other disparities.
The Minnesota Department of Health describes health equity as “addressing health disparities as part of a broad spectrum of public investments in housing, transportation, education, economic opportunity and criminal justice.” By implementing changes and integrating health equity goals into core operational frameworks, the hope with the IHP 2.0 program is to overcome the limitations of traditional health care approaches in addressing SDOH and health disparities that arise as a result.
In fact, recent case studies on Medicaid payment reforms conducted by the Urban Institute directly referenced and cited Minnesota’s IHPs, describing their influence on health equity along with the overall changes made to the program in 2018 in order to continue to advance equity in Medicaid.
The table below from the Urban Institute identifies and describes the core features of the IHP 2.0 program designed to both focus on and advance equity for beneficiaries.
Source: Allen & Willis, “Can Medicaid Payment and Purchasing Strategies Advance Health Equity?” The Urban Institute, December 2023, https://www.urban.org/sites/default/files/2023-12/Can%20Medicaid%20Payment%20and%20Purchasing%20Strategies%20Advance%20Health%20Equity_0.pdf
As described above, the success of IHPs is evaluated based on performance in health care quality, utilization, health equity, and total cost of care (TCOC). When monitoring quality for those in risk arrangements where quality has an impact on shared savings and losses, the quality-related assessments are organized into five domains.
As a reminder, those domains are as follows:
- Quality Core Set
- Care for Children and Adolescents
- Quality Improvement
- Closing Gaps
- Equitable Care
Two of these domains, “Closing Gaps” and “Equitable Care,” specifically target health equity through tailored clinical and utilization measures aimed at reducing and eliminating disparities among specific Medicaid populations. IHPs can also receive ‘bonus points’ on their overall quality score for creating additional initiatives under the Quality Improvement, Closing Gaps, and Equitable Care domains.
Recent Health Equity Interventions
As a part of the enhanced focus on health equity, IHPs are encouraged to design interventions to address targeted populations’ health equity challenges.
Target populations may differ among the IHPs, with some initiatives aimed at supporting the entire IHP patient population and some designed to serve a more specific sub-population. A summary list of common target populations of Minnesota’s 25 IHPs include:
- Children, adolescents, families, and new mothers
- Justice-involved individuals
- Patients with a mental illness or individuals living with a family member with a mental illness
- Patients that are food insecure
- Adults with substance use disorder
- Individuals experiencing challenges accessing care, including Black, Indigenous, and people of color
A summary list of common social risk factors across Minnesota’s 25 IHPs include:
- Housing instability
- Food insecurity
- Social isolation
- Transportation
- Difficulty paying bills
- Education
- Employment
- Mental health needs
- Access to care
- Language barriers
- Income
- Childcare
IHPs must first identify the population or populations that they are serving, and then they must design, develop, and implement targeted intervention efforts based on those populations, risk factors, and SDOH to advance equity for those groups. IHPs are encouraged to identify an intervention that will meet the needs of their specific population given their knowledge of their community. Examples of these efforts include community partnerships, screening initiatives, referrals to community resources or other needed programs, and care coordination for social needs. The following is a summary list of common interventions currently being used to address health equity across Minnesota’s 25 IHPs:
For a full list, the Health Equity Interventions Summary at this link provides the specific target population, social risk factors, interventions, and milestone components for each IHP in Minnesota.
Closing Thoughts
As DHS’ IHP Program continues to evolve, its focus on data analytics and population health management remains pivotal for achieving comprehensive care delivery and advancing health equity statewide. The IHP 2.0 Program exhibits the importance of translating equity-focused policy goals into actionable requirements and programs. DHS’ work to monitor and disseminate the outcomes of the health equity initiatives and interventions implemented by IHPs will continue to provide valuable insights into their effectiveness and impact on Minnesota's health care landscape.
One potential dissemination method would be to make the Population Health Reports from IHPs publicly available. This would not only increase transparency around the data collected by IHPs and the lessons learned from putting interventions into practice, but also aid in our understanding of the effectiveness of IHPs in addressing SDOH, improving access to care, and eliminating health disparities.
Continue learning about health equity in Medicaid and beyond with the following SHADAC products:
Notes
Publication
Reproductive Oppression in Health Care: Underlying Factors of Medicaid Inequities Annotated Bibliography
*Click here to jump to the 'Reproductive Oppression in Health Care' annotated bibliography*
The State Health Access Data Assistance Center (SHADAC) with support from the Robert Wood Johnson Foundation (RWJF) and in collaboration with partner organizations is exploring whether a new national Medicaid Equity Monitoring Tool could increase accountability for state Medicaid programs to advance health equity while also improving population health.
During the first phase of this project, a conceptual wireframe for the potential tool was created. This wireframe includes five larger sections, organized by various smaller domains, which would house the many individual concepts, measures, and factors that can influence equitable experiences and outcomes within Medicaid (see full wireframe below).
While project leaders and the Advisory Committee appointed at the beginning of the project all agree that the Medicaid program is a critical safety net, they specifically identified the importance and the need for an “Underlying Factors” section of the tool. This section aims to compile academic research and grey literature sources that explain and provide analysis for the underlying factors and root causes that may contribute to inequities in Medicaid.
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- Historical context of Medicaid inequities
- Information on how underlying factors perpetuate inequities in Medicaid
- Potential solutions for alleviating inequities within Medicaid
Once selected, researchers compiled sources in an organized annotated bibliography, providing a summary of each source and its general findings. This provides users with a curated and thorough list of resources they can use to understand the varied and interconnecting root causes of Medicaid inequities. Researchers plan to continually update this curated selection as new research and findings are identified and/or released.
Sections of the full annotated bibliography include:
- Systemic Racism
- Systemic / Structural Ableism
- Sexual Orientation, Gender Identity, and Gender Affirming Care Discrimination
- Reproductive Oppression in Health Care
- Impact on Vital Community Conditions
This page is dedicated to a single section from the full annotated bibliography:
Reproductive Oppression in Health Care
Underlying Factors Annotated Bibliography: Reproductive Oppression in Health Care
Have a source you'd like to submit for inclusion in our annotated bibliography? Contact us here to propose a source for inclusion.
Click on the arrows to expand / collapse each source.
Crear-Perry, J., Correa-de-Araujo, R., Lewis Johnson, T., McLemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women's Health (2002), 30(2), 230–235. https://doi.org/10.1089/jwh.2020.8882
Author(s): Joia Crear-Perry, National Birth Equity Collaborative, Washington D.C.; Rosaly Correa-deAraujo, Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health; Tamara Lewis Johnson, Office of Disparities Research and Workforce Diversity, National Institute of Mental Health, National Institutes of Health; Monica R. McLemore, Family Health Care Nursing Department & Advancing New Standards in Reproductive Health, University of California San Francisco; Elizabeth Neilson, Office of Disease Prevention, Office of the Director, National Institutes of Health; Maeve Wallace, Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine
Article Type: Peer-reviewed Journal
The authors of this article make a distinction between structural and social determinants of health, describing structural determinants as the “cultural norms, policies, institutions, and practices that define the distribution (or maldistribution)” of social determinants of health. The authors explore these concepts in the context of social determinants of maternal health. They present a theoretical framework of determinants of Black maternal health called “Restoring Our Own Through Transformation” (created by Jessica Roach, 2016) to illustrate a “web of causation” between structural and social determinants of health and wellness. Crear-Perry et al. explore structural determinants of maternal health that are features of the U.S. health care system including financial barriers to care, a shortage of primary care providers, and gaps in quality, while also considering policy levers that might improve structural factors to support better maternal health outcomes, like paid family leave, access to affordable and comprehensive health care (which could be measured using exposure to Medicaid expansion, having Medicaid coverage through 12 months postpartum, etc.), access to culturally appropriate care (e.g., with clinicians that have received education on structural determinants of health and health inequities—i.e. “structural competency” education), and investments in community-oriented primary care for diverse women of reproductive age (e.g., midwifery maternity centers, nurse practitioner practices, maternal and child clinics, etc.).
Morcelle, M.T. (2022). Reforming Medicaid Coverage Toward Reproductive Justice. American Journal of Law & Medicine, 48, 223–243. https://doi.org/10.1017/amj.2022.27
Author(s): Madeline Morcelle, Senior Attorney in the National Health Law Program's (NHeLP) Washington, D.C. Office
Article Type: Peer-reviewed journal
The author of this journal article argues that while Medicaid presents a powerful vehicle for reproductive justice, especially for Black people and people of color, its structure allows for discriminatory eligibility and coverage policies that worsen health inequities for adults and their children. Historically, women and people of color have been advocating against reproductive oppression and advocating for “...universal, comprehensive, and affordable health coverage and access, with strong nondiscrimination protections, for everyone.” However, the author describes how voices of those experiencing oppression need to be centered or part of an “open source” framework rather than a “bottom to the top” engagement to dismantle oppressive systems. The author explains how Medicaid was designed by whites in power to only provide access to health coverage for some, “...the ‘worthy poor’,” and that these discriminatory practices continue today through policy decisions, like making Medicaid expansion a choice, for example. The author also describes the lack of adequate benefits for certain populations. While advances have been made recently, namely the Medicaid postpartum coverage extension opportunity and options to cover some immigrant groups, reproductive justice voices and frameworks should be at the center of Medicaid reform efforts to stop reproductive oppression and advance health equity for all.
Thompson, T. M., Young, Y.-Y., Bass, T. M., Baker, S., Njoku, O., Norwood, J., & Simpson, M. (2022). Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South. Health Affairs, 41(2), 195–202. https://doi.org/10.1377/hlthaff.2021.01422
Author(s): Terri-ann Monique Thompson & Yves-Yvette Young, Ibis Reproductive Health, Tanya M. Bass, North Carolina Central University, Stephanie Baker, Elon University, Oriaku Njoku, Access Reproductive Care–Southeast, Jessica Norwood, The Runway Project, Monica Simpson, SisterSong Women of Color Reproductive Justice Collective
Article Type: Peer-reviewed journal
This article details a community-based participatory research approach to focus groups with nearly 50 Black women living in both Georgia and North Carolina (states chosen for having relatively restrictive reproductive health policies) to understand their experiences interacting with reproductive health care. The research team focused on three aspects of the participants’ experiences: access to health care, use of health care, and experience in health care – and how these experiences were connected to structural (summarized here) and individual racism. In terms of structural factors and access to adequate care, findings include that reproductive health clinics were often located outside of participants’ communities, making accessing care difficult. Focus group participants covered by Medicaid experienced issues with copayment being too burdensome. Lack of abortion coverage in some states was also a major concern for participants. In terms of structural racism and service use, authors report inconsistencies in what services are covered by different plans (both private and Medicaid coverage are mentioned), which impacted utilization. Focus group participants also reported that being a Black woman or living in a predominately Black community and receiving public assistance (or being uninsured) negatively impacted their health care experiences. Further, there was a perception that facilities caring for primarily publicly-insured individuals were lower quality. The authors urge for policy actions that alleviate these structural barriers, such as expanding federally funded Medicaid coverage, requiring abortion coverage, increasing reimbursement for doulas and midwives, and investing in hospitals that provide uncompensated care.
Ogunwole, S. M., Karbeah, J., Bozzi, D. G., Bower, K. M., Cooper, L. A., Hardeman, R., & Kozhimannil, K. (2022). Health Equity Considerations in State Bills Related to Doula Care (2015-2020). Women's Health Issues: Official publication of the Jacobs Institute of Women's Health, 32(5), 440–449. https://doi.org/10.1016/j.whi.2022.04.004
Author(s): S Michelle Ogunwole, Department of Medicine, Johns Hopkins University School of Medicine & John Hopkins Center for Health Equity; J’Mag Karbeah and Katy Kozhimannil, Division of Health Policy and Management, University of Minnesota School of Public Health; Rachel Hardeman, Center for Antiracism Research for Health Equity & Division of Health Policy and Management, School of Public Health, University of Minnesota; Debra G Bozzi, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Kelly M. Bower, Johns Hopkins University School of Nursing, & Johns Hopkins Center for Health Disparities Solutions; Lisa A. Cooper, Department of Medicine, Johns Hopkins University School of Medicine, Departments of Health Policy and Management, Health, Behavior, and Society, and Epidemiology, Johns Hopkins Bloomberg School of Public Health
Article type: Peer-reviewed journal
This article presents findings from a landscape analysis of state legislation related to doula care, including Medicaid coverage and reimbursement, with specific attention to whether legislation addresses racial health equity. It is well known that disparities in birth outcomes disproportionately affect Black and Indigenous birthing people. And evidence suggests that doula care is associated with improved birth outcomes. Authors draw on reproductive justice and public health critical race praxis frameworks in formulating study questions and methods. Reproductive justice refers to women having autonomy over their own bodes and the right to have and parent children safely and with access to community supports to realize optimal reproductive health. Public health critical care praxis theory acknowledges the legacy of white supremacy and racism as a root cause of health inequities in public health research. Authors draw on this theory to develop criteria for assessing whether doula care legislation is designed to address racial health equity. Criteria included reimbursement with plans to provide a living wage, collaboration with community-based doulas, training and certification requirements and funding, and emphasis on workforce diversity, promising practices, and metrics. Authors found that of the 73 bills introduced by 24 states between 2015 and 2020, just over half focused on Medicaid reimbursement for dual care. (Twelve bills in seven states became law.) However, only two states that passed Medicaid reimbursement for doulas also met some of the authors criteria for racial equity in their laws. Authors conclude that while proposals for increased access to doula care have increased over time, a racial equity lens is lacking. Authors suggest engaging doulas and considering racial equity policy assessments in the legislative drafting process.
[1] Women's Leadership and Resource Center. (2023). Reproductive Oppression Against Black Women | Women’s Leadership and Resource Center | University of Illinois Chicago. Wlrc.uic.edu; University of Illinois Chicago. https://wlrc.uic.edu/reproductive-oppression-against-black-women/
Publication
Language Barriers and Health Equity: The Challenges Faced by Californians with Limited English Proficiency (CHCF Cross-Post)
The following is cross-posted from The California Health Care Foundation.
Author: Lacey Hartman, Senior Research Fellow, SHADAC
Key Takeaways
California is home to approximately 2.7 million adults with Limited English Proficiency (LEP), according to the California Health Interview Survey. They face significant health care challenges and disparities:
- Economic and insurance disparities. People with LEP are more likely to have lower incomes, be uninsured, or enrolled in public health insurance programs.
- Health status and discrimination. They often report fair or poor health status, experience discrimination within the health care system, and more likely identify as Latino/x.
- Communication barriers. People with LEP frequently have trouble understanding health care providers and are less likely to access telehealth services or have a usual place to go for care.
- Use of informal interpreters. Among people with LEP, 29% rely on family members or friends for help understanding their doctors, and 23% are unaware of their right to an interpreter.
California has a significant population with limited English proficiency (LEP), composing 25% of people with LEP in the U.S. age five and older. This group typically has less access to health coverage and care, leading to poorer health outcomes, and these challenges are often compounded by systemic racism and discrimination.
This brief uses pooled data from the 2021 and 2022 California Health Interview Survey to provide a comprehensive overview of adults with LEP in California. The data highlight their demographic characteristics, access to care, health outcomes, and communication challenges with health care providers. The brief concludes with policy implications and areas for future research to better support this vulnerable population.
The research showed that on some measures, people with LEP fare the same or better than English-proficient Californians. For example, they are no more likely to have missed a doctor visit in the past year or to have trouble finding a doctor. They are also less likely to delay or go without needed care. These findings suggest a need for further research to fully understand the experiences and barriers faced by those with LEP.
You can read the full brief here or by clicking the image to the right.
Blog & News
Disability Health Care Data and Information: Resources from SHADAC
August 08, 2024:- Unfair treatment in health care settings, at work, or when applying for public benefits
- Adults with disabilities are more likely to live in poverty compared to adults with no disability
- People with a disability often have increased medical expenses, with a study from the National Disability Institute estimating that a U.S. household containing an adult with a disability must spend an estimated 28% more income to obtain the same standard of living as a household with no disability
- Those with disabilities have twice the risk of developing chronic health conditions like depression, diabetes, asthma, and poor oral health
Federal Survey Sample Size Analysis: Disability, Language, and Sexual Orientation and Gender Identity
- People who indicated sexual orientation or gender identity (SOGI)
- People with language access needs, and
- People with disabilities
Collection of Self-Reported Disability Data in Medicaid Applications: A Fifty-State Review of the Current Landscape (SHVS Brief)
State Health Compare Disability Breakdowns
Housing Affordability Matters: Unaffordable Rents Infographics Updated with 2022 Data
Minnesota Community and Uninsured Profile
Stay Informed on Disability Health Data Resources and Information
Blog & News
Provider Discrimination Based on Sexual Orientation and Gender Identity: Experiences of Transgender/Nonbinary Adults and Sexually Minoritized Adults in Minnesota
September 03, 2024:Background
Understanding the experiences of people with minoritized sexual and gender identities matters for public health. Compared with straight and cisgender adults, these populations face inequitable barriers to health care access1,2 and disparities in health outcomes, including mental and physical health, activity limitations, and chronic conditions.3,4 Accordingly, Sexual Orientation and Gender Identity (SOGI) data collection is foundational in advancing population health and health equity in order to better understand the disparities and inequities these populations face.
As highlighted in our previous blogs, one focused on populations by sexual orientation and the other focused on populations by gender identity, reports of discrimination from health care providers based on sexual orientation or gender identity are high among people with minoritized sexual and gender identities. This discrimination is associated with barriers to health care access. For example, individuals who report discrimination may not receive proper treatment from discriminatory providers, and they may forgo or delay health care to avoid discrimination. Across populations, experiencing discrimination has been shown to negatively affect mental and physical health.5
In this blog, we build on these results by pooling two years of data to look at people’s experiences at the intersection of minoritized sexual and gender identities in reports of provider discrimination based on gender or sexual orientation. We used a survey question asking, ‘how often their gender, sexual orientation, gender identity or gender expression cause health care providers to treat them unfairly.’ Our analysis also illustrates how the commonly used measures for sexual orientation do not adequately encompass the range of options for sexually minoritized people, and how these limitations disproportionately impact the transgender and nonbinary populations.
Study Approach
We used 2021-2023 data from the biennial Minnesota Health Access Survey (MNHA). See Methods here.
Results
Among all adults in Minnesota, over half of the transgender/nonbinary population (56.3%) reported experiencing provider discrimination based on sexual orientation or gender identity – significantly higher compared with cisgender adults’ reported experiences of discrimination (6.7%) (Table 1).
Table 1. Rates of SOGI-Based Provider Discrimination by Sexual Orientation Among Cisgender Adults and Transgender/Nonbinary Adults in Minnesota, 2021-2023.
| Cisgender | Transgender/Nonbinary | ||
| All Adults (18+) | 6.7% | 56.3% | * |
| Sexual Orientation | |||
| Straight | 4.9% | -- | -- |
| Gay or Lesbian | 24.1% | 88.1% | * |
| Bisexual or Pansexual | 31.6% | 40.5% | |
| None of These | 23.9%† | 66.2% | * |
* Significant difference between cisgender and transgender/nonbinary adults in reports of provider discrimination.
† Estimate may be unreliable due to limited data (relative standard error greater than or equal to 30%).
-- Estimate not available to limited data.
Source: SHADAC analysis of the 2021-2023 Minnesota Health Access Survey.
When delving into experiences of provider discrimination among people with diverse gender and sexual identities, we found that reports of provider discrimination from transgender/nonbinary adults who identified as gay/lesbian or ‘none of these’ were significantly higher than for cisgender adults who identify as gay/lesbian or ‘none of these.’
Specifically, provider discrimination based on gender or sexual orientation was reported by:
- Nearly 9 in 10 transgender/nonbinary adults (88.1%) and about one in four (24.1%) cisgender adults who identified as gay/lesbian
- Two thirds of transgender/nonbinary adults (66.1%) and about a quarter of cisgender adults (23.9%) that chose the ‘none of these’ option for sexual orientation
Provider discrimination was also high for people who identified as bisexual/pansexual, and, for this group, not significantly different for transgender/nonbinary adults (40.5%) and cisgender adults (31.6%).
The lowest rates of provider discrimination were reported by straight cisgender adults at 4.9%.
Please note that sample sizes were limited, particularly for comparing straight or bisexual/pansexual adults by gender.
Discussion
Consistently across sexual orientations, reports of provider discrimination based on gender or sexual orientation were higher for transgender/nonbinary adults compared with cisgender adults. This suggests that discrimination associated with sexual minoritization may disproportionately impact transgender/nonbinary populations.
Individuals that experience multiple minoritized identities must contend with discrimination on multiple levels. For example, someone may experience discrimination based on a combination of their sexual orientation, gender identity, race, and/or disability status. Looking at the data from this study, we can illustrate this idea looking at provider discrimination reported by gay/lesbian cisgender adults and gay/lesbian transgender/nonbinary adults. Both of these groups share the same sexual orientation, but differ in gender identity. The group with multiple minoritized identities, the gay/lesbian transgender/nonbinary group, reported significantly higher rates of discrimination (88.1%) compared to cisgender gay/lesbian adults (24.1%), which may be related to their multiple levels of marginalization.
Overall, though, our analysis finds that discrimination remains alarmingly high across all groups of people with minoritized sexual and/or gender identities. Looking across the Minnesota population, this study documents provider discrimination among both transgender/nonbinary and cisgender sexual minorities, including people who identify as gay/lesbian, bisexual/pansexual, or ‘none of these.’
Our study also shows the importance of providing data for groups outside of the largest categories such straight, gay/lesbian, or bisexual. For example, by pooling multiple years of data, we were able to produce estimates for gender and sexual minorities including people who responded ‘none of these’ for sexual orientation. This latter group is important to highlight considering the wide range of sexual identities beyond gay/lesbian, straight, and bisexual. Reports of discrimination were high for both transgender/nonbinary and cisgender people who responded ‘none of these’ for sexual orientation, and significantly higher for the transgender/nonbinary people compared with cisgender.
This study highlights continued evidence of health care provider discrimination in Minnesota, with transgender/nonbinary sexual minorities being particularly impacted. Policies are urgently needed to address this discrimination, particularly for transgender/nonbinary Minnesotans who already face barriers to health care access and disparities in health outcomes compared to cisgender adults.
METHODS
Data
The 2021-2023 Minnesota Health Access (MNHA) survey is a biennial population-based survey on health insurance coverage and access conducted in collaboration with the Minnesota Department of Health. We limited the analysis to adults responding for themselves about experiences of discrimination (n=17,828), and we excluded proxy reports (e.g., a household member answering for a spouse or roommate).
Discrimination Based on Sexual Orientation and Gender Identity in the MNHA Survey
To study discrimination, we looked at a survey question that asks respondents ‘how often their gender, sexual orientation, gender identity or gender expression cause health care providers to treat them unfairly.’ Responses of ‘never’ were coded as no discrimination, and responses of ‘always,’ ‘usually,’ or ‘sometimes’ were coded as discrimination.
Sexual Orientation Measures in the MNHA Survey
Similar to other surveys that collect sexual orientation data, the MNHA asks about sexual orientation using three main response options: ‘gay or lesbian’; ‘straight, that is, not gay or lesbian’; and, ‘bisexual or pansexual.’ Survey respondents could also select ‘don’t know’ or ‘none of these,’ with an option to write in their own answer. We reviewed write-in responses and, when possible, recoded these responses to align with the existing categories.
Recoding write-in responses was a key step in reducing the risk of misclassification in order to include people who selected ‘none of these’ for sexual orientation in analysis. Some straight adults are unfamiliar with terminology for sexual orientation, which can lead to inaccurate responses.6 We reclassified inappropriate write-in answers (such as man, woman, married, or offensive comments) as ‘refused.’
After this step in cleaning the data, we tabulated results separately for two groups: people who responded ‘none of these’ with no write-in, and those who responded ‘none of these’ with an LGBTQ+ write-in response such as ‘queer’ or ‘asexual.’ Rates were similar, which helped to justify combining these subgroups into a single ‘none of these’ variable to improve sample size and produce estimates of reported discrimination for this subpopulation.
MNHA measures of sexual orientation were generally consistent with current best practices (for more information on SOGI data collection practices in Medicaid click here, and click here for our brief on federal survey sample size analysis), our analysis highlights some limitations of commonly used survey measures for sexual orientation. A small difference in the MNHA from typical measures is the inclusion of ‘bisexual or pansexual’ rather than only ‘bisexual’ as a response option. Current recommendations suggest using the phrasing, ‘I use a different term,’ rather than ‘none of these’ as a response option.7
Gender Identity Measures in the MNHA Survey
In 2023, the MNHA switched from a single question measuring gender to a two-step question asking first, ‘how do you describe your gender,’ and second, ‘are you transgender.’ As described in a previous blog, this approach was developed by the Oregon Health Authority through extensive community engagement and has advantages of being clear and inclusive.8 Response options for gender were:
- Man
- Woman
- Gender non-binary or two-spirit
- Agender/no gender
- Another gender (optional write in response)
In contrast, 2021 response options included ‘transmale/transman’ and ‘transfemale/transwoman’ listed after ‘male/man’ and ‘female/woman,’. Although current best practice recommendations for federal surveys list ‘transgender’ as response option after male/female, this approach has the limitation of implying that being transgender is ‘other’ and mutually exclusive from male/female. Similarly, the two-step question currently recommended for federal surveys asks about ‘sex assigned at birth,’ which may be perceived as invalidating and adds cognitive burden, especially for people with low literacy. Using accessible language in survey questions supports user experiences and overall response rates, and helps to reduce data quality problems such as item non-response and misclassifications. Guidance developed by the state of Oregon offers an inclusive approach to measuring gender on population surveys.
Analysis
We tabulated gender and sexual orientation based discrimination by sexual orientation for cisgender and transgender/nonbinary adults in Minnesota. For transparency, we present results for all response categories, even if estimates must be suppressed due to lack of data. Tests for statistical significance were conducted at the 95% confidence level.
References
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