3 key LGBTQ+ healthcare concerns — and ways to prepare
Use these tips to plan ahead for the potential costs of family planning, long-term care and gender-affirming care
By Patty Onderko
HEALTHCARE COSTS ARE A CRITICAL ELEMENT in everyone’s financial strategy — but they take on heightened importance for members of the LGBTQ+ community. “Healthcare comes up in nearly every conversation with a new client,” says Merrill Financial Advisor Mariam Adams, chair of the New York City chapter of Merrill’s LGBTQ+ National Team. In fact, according to an in-depth study conducted by Merrill, affluent LGBTQ+ individuals are one-third more likely to be concerned about paying for medical care than the general affluent population.1
The costs of three areas in particular — family planning, long-term care and gender-affirming healthcare — are top of mind for many LGBTQ+ clients. With proper planning, however, medical expenses can be managed without compromising your other important financial goals, says Adams. Here are some strategies that could help.
How to prepare for long-term care
Long-term care expenses can be problematic for LGBTQ+ individuals because they are less likely to have children to rely on. According to the U.S. Census Bureau, only 15% of same-sex couples are raising children, compared with 38% of married heterosexual couples.2 And childless LGBTQ+ couples, as well as singles, are generally on their own for care as they age. Without family support, you may need to plan workarounds, which can be expensive.
Affluent LGBTQ+ individuals are one-third more likely to be concerned about paying for medical care than the general affluent population.1
But there are steps you can take to help ensure that long-term care will be there if you need it. Start by making sure you select a trusted friend or family member to hold your power of attorney for both health and financial decisions. And talk to your advisor about insurance policies designed to address the issue of care — including long-term care insurance, which will cover some of the costs either in your home or in a nursing facility, or permanent life insurance with a long-term care rider. Also, do some research and ask friends and allies for help identifying long-term care facilities that respect LGBTQ+ elders.
That sort of advanced planning worked for an LGBTQ+ client of Merrill Wealth Advisor William J. Moran. “When he came to me for help planning his retirement, we talked not only about achieving his immediate goals — moving south to help his elderly mother and living comfortably on his pension — but about the ‘what-ifs’ of aging,” Moran says. A few years later, the man, in his 70s, was injured in a fall and required daily rehab. Because of the preparation he had made with Moran’s help, he was able to make the transition to a welcoming assisted living facility of his own choosing, where he now lives.
A financial strategy for family planning
Sixty-three percent of LGBTQ+ individuals under age 35 say they want to expand their families, either by becoming parents for the first time or by having more children, according to a study by the Family Equality Council.7 That frequently involves assisted reproductive technology (ART), surrogacy and/or adoption — all pricey undertakings. A single round of in vitro fertilization (IVF), for example, can cost $25,000 or more, depending on where you live. While many insurers offer coverage — in fact, it’s mandatory in 14 states — many cap the amount covered or limit the number of IVF cycles allowed. Surrogacy costs run even higher, often more than $125,000, and nearly 10% of LGBTQ+ people who hope to become parents plan on turning to surrogacy, according to a recent survey by the Center for LGBTQ Economic Advancement & Research (CLEAR) and the Movement Advancement Project.8
While it’s illegal for insurance companies to discriminate against people for their sexual orientation, loopholes exist for family planning that can create additional costs for LGBTQ+ couples. As LGBTQ+ individuals, when my wife and I began trying to start a family, we had insurance coverage for the ART we needed so that I could become pregnant with a donor. However, before we could qualify for reimbursement, our insurance required us to provide “proof of infertility” by showing that we had tried, on our own, to get pregnant for a full year. We never quite understood how they thought two cisgender women in a monogamous relationship could “try” to conceive a child without ART. But our now-15-year-old twin boys are worth every penny of our quite expensive out-of-pocket healthcare costs.
That’s a sentiment shared by Toni Peterson, market executive for Merrill’s Nevada market and a member of Bank of America’s LGBTQ+ Executive Leadership Council. Peterson and her partner have already gone through a combined four rounds of IVF — once for Peterson, three times for her partner. Each round cost $25,000 to $30,000 — and none led to a pregnancy. “We keep saying that if we end up with a baby at the end of it, we won’t even think about the fact that we’ve spent something like $200,000 doing this stuff,” Peterson says. “Check whether your health insurance policy covers IVF or other ART procedures,” suggests Adams. “Then you can begin to figure out how much you should set aside for family planning.”
Changing jobs? Consider negotiating additional benefits and coverage for procedures such as gender-affirming surgery or IVF.
Securing transgender health and wellness
Gender-affirming healthcare can include psychological counseling, hormone therapy and surgeries, such as facial surgery, top surgery or bottom surgery, and the total cost can easily exceed $100,000. Frequently, gender-affirming care is not covered by insurance; some insurers consider many of the necessary procedures elective and decline to cover them. In the CLEAR survey, 25% of those who had received gender-affirming care reported spending $20,000 or more out of pocket; another 33% spent $10,000 or more.9
New state laws limiting gender-affirming care could change the landscape even more. According to a recent analysis by the Williams Institute at the UCLA School of Law, nearly 150,000 transgender youth are at risk of losing access to gender-affirming medical care altogether.10
One of Adams’ clients was “considering how soon they can get gender-affirming surgery,” she says. “When they started factoring in non-covered procedures, like facial feminization surgery and time off for the procedures, the price really started to add up.” They were able to cash in some maturing stock options, says Adams, adding, “between that and saved vacation days, plus a strong support network at work, they were in a good financial position to move forward, because we planned for it.”
Ways you can save for potential medical needs
“The LGBTQ+ individuals I work with do have one very real advantage in planning for healthcare costs: They’re generally more aware of the potential financial challenges, which can give them an incentive to save aggressively early on,” says Moran. Working with a financial advisor, you can incorporate future healthcare costs into your long-term priorities, along with other important goals, such as purchasing a home or retiring.
To help save for and manage costs, Adams suggests considering a health savings account; in combination with a high-deductible health plan, it allows you to save pre-tax dollars to pay for qualified medical expenses not covered by insurance. She also encourages those age 50 and over to take advantage of the catch-up provision allowing them to contribute even more to their 401(k)s or IRAs. Saving more for retirement helps to ensure that you’ll be able to afford the healthcare you need as you grow older.
“Making the most of the coverage you have is a big part of working toward realizing all of your dreams,” says Adams. Advocating for improved coverage can also help. Adams suggests to her LGBTQ+ clients who are changing jobs that they negotiate additional benefits and coverage for procedures such as gender-affirming surgery or IVF. As companies increasingly value inclusivity in the workforce, they may be more open to offering expanded coverage — and that could benefit everyone.
Patty Onderko has covered health, family, psychology and LGBTQ+ topics for national publications including Parenting, Success, HealthCentral.com and many more. She lives with her wife and sons in Brooklyn, New York.
1 Merrill and Ipsos, “Diverse Viewpoints: Exploring Wealth in the LGBTQ+ Community,” 2022.
2 U.S. Census Bureau, “Characteristics of Same-Sex Couple Households: 2005-Present,” 2022.
3 Genworth, “Cost of Care Survey,” January 2022.
4 Genworth, “Cost of Care Survey,” January 2022.
5 American Society of Reproductive Medicine, accessed 2023, and Forbes Health, “How Much does IVF Cost?” March 2023.
6 The Journal of Law, Medicine & Ethics, “Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population,” Fall 2022.
7 Family Equality Council, “LGBTQ Family Building Survey,” January 2019.
8 Center for LGBTQ Economic Advancement & Research and the Movement Advancement Project, “The LGBTQI+ Economic and Financial (LEAF) Survey: Understanding the Financial Lives of LGBTQI+ People in the United States,” March 2023.
9 Center for LGBTQ Economic Advancement & Research and the Movement Advancement Project, “The LGBTQI+ Economic and Financial (LEAF) Survey: Understanding the Financial Lives of LGBTQI+ People in the United States,” March 2023.
10 Williams Institute, UCLA School of Law, “Prohibiting Gender-Affirming Medical Care for Youth,” March 2023.
Merrill, its affiliates, and financial advisors do not provide legal, tax, accounting or benefits consulting advice. You should consult your legal and/or tax advisors before making any financial decisions.
Long-term care insurance coverage contains benefits, exclusions, limitations, eligibility requirements and specific terms and conditions under which the insurance coverage may be continued in force or discontinued. Not all insurance policies and types of coverage may be available in your state.
This material should be regarded as general information on health-care considerations and is not intended to provide specific health care advice or imply that Merrill Financial Advisors can now or in the future provide specific health care advice. Questions regarding health care situations should be directed to health care, legal or tax professionals.