Protecting safety-net equity monitoring after federal sexual orientation and gender identity data rollbacks.

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Learn more: PMC Disclaimer | PMC Copyright Notice Health Aff Sch . 2026 May 21;4(6):qxag124. doi: 10.1093/haschl/qxag124 Protecting safety-net equity monitoring after federal sexual orientation and gender identity data rollbacks Dhruv Khurana 1, ✉ , Andrew Short 2 Author information Article notes Copyright and License information 1 Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States 2 Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States ✉ Corresponding author: Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States. Email: dhruvkhurana@g.ucla.edu Received 2026 Feb 26; Revised 2026 May 12; Accepted 2026 May 15; Collection date 2026 Jun. © The Author(s) 2026. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. PMC Copyright notice PMCID: PMC13235683  PMID: 42253878 Abstract Recent federal actions have weakened sexual orientation and gender identity (SOGI) data collection across safety-net systems, threatening the capacity to measure and govern SOGI health disparities. A January 2025 executive order directed agencies to eliminate gender identity data from federal programs and surveys; many agencies applied it to sexual orientation as well: of approximately 360 affected federal data collections, 338 removed gender identity questions and 60 removed sexual orientation questions, reflecting disproportionate targeting of gender identity data. Subsequent rescissions in June 2025 of guidance on SOGI data collection in Medicaid and federal health center reporting have further dismantled equity accountability infrastructure. Drawing on whole-person health screening data from >35 000 safety-net patients, we emphasize 2 policy-relevant patterns: a “generational reversal” (largest disparities concentrated among younger LGB+ adults; eg, depression rates 24 percentage points higher among LGB+ adults ages 18-25, shrinking to 7 points by age 46 and older) and an “education paradox” (higher educational attainment alongside greater material hardship). Illustrative interviews with 7 LGB+ adults stress-tested policy implications and helped incorporate community interpretation. We propose SOGI data accountability mechanisms, workflow-embedded warm handoffs, and contracting and workforce strategies to reduce discrimination exposure and improve access to benefits and preventive care. Keywords: sexual orientation, SOGI, safety-net, health equity, Medicaid, HRSA, Uniform Data System, EHR, whole-person screening, Whole PERSON Health Score, social needs, warm handoff, discrimination, workforce policy, quality measurement Key points. Whole-person screening evidence shows disparities are concentrated among younger LGB+ adults across multiple domains, depression rates are 24 percentage points higher at ages 18-25 (shrinking to 7 points by age 46+), with parallel gradients observed in food insecurity, financial hardship, and transportation barriers, implying safety-net targeting and accountability metrics should prioritize younger cohorts ( Figure 1 ). The “education paradox” is a policy signal: higher educational attainment coexists with greater material hardship, indicating education-only approaches will not close LGB+ economic gaps without anti-discrimination and benefits-access mechanisms. Disparities are measurable only when structured sexual orientation and gender identity (SOGI) data exist; when SOGI capture is reduced or removed, as with the 2025 Centers for Medicare and Medicaid Services rescission and Health Resources and Services Administration Uniform Data System changes, the denominator for equity accountability disappears. Figure 1. Open in a new tab Generational reversal in LGB+ health disparities. Average marginal effects vs heterosexual peers by age group (18-25, 26-45, 46+). Dark blue indicates LGB+ (patients who selected Lesbian, Gay, Lesbian or Gay, Bisexual, Pansexual, Asexual, or Something else) vs heterosexual; light blue indicates “Other” (patients who selected “choose not to disclose” or “do not know” for sexual orientation) vs heterosexual. Error bars show 95% confidence intervals. Faded bars indicate estimates whose 95% confidence intervals include zero (not statistically significant). Both LGB+ and “Other” respondents are compared against a common heterosexual reference group rather than against each other. The “Other” category includes respondents who selected “choose not to disclose” or “do not know,” a heterogeneous group whose composition spans undisclosed identities, sexual fluidity, and survey satisficing; measurement literature documents that this category does not represent a stable or coherent analytical group, making direct LGB+-to-Other comparison substantively uninterpretable. Displaying both groups against the shared reference allows readers to assess whether “Other” respondents show a distinct disparity pattern without implying the 2 groups are directly comparable. Policy problem: losing denominators Recent federal actions have weakened routine sexual orientation and gender identity (SOGI data collection and reporting, increasing the risk that safety-net systems will lose the denominators needed to measure and govern LGBTQ+ health disparities. Executive Order 14 168 (January 20, 2025) directed federal agencies to eliminate gender identity (GI) data from programs and surveys (Section 3(e)); while the order does not explicitly mandate removal of sexual orientation (SO) data, numerous agencies have cited it as justification for removing both GI and SO measures. A recent analysis found that of approximately 360 affected federal data collections, 338 removed GI questions while 60 removed SO questions, illustrating that GI data have been disproportionately targeted and that SO removals are often proceeding beyond what the order strictly requires. 1-3 These include the National Health Interview Survey, the Medicare Current Beneficiary Survey, and the National Crime Victimization Survey, eliminating data sources that Centers for Medicare and Medicaid Services (CMS) itself had previously described as irreplaceable. 4 In June 2025, CMS rescinded guidance on SOGI data collection in Medicaid and Children's Health Insurance Program applications 5 ; separately, Health Resources and Services Administration's (HRSA) CY2025 Uniform Data System (UDS) updates removed SOGI elements from required reporting 6 : directly affecting Federally Qualified Health Centers (FQHCs), which serve as the primary safety-net providers for low-income and uninsured populations and whose equity reporting obligations flow through the UDS. 7 Together, these actions constitute a coordinated cross-agency dismantling of the data infrastructure on which equity accountability depends, a pattern documented across federal health, justice, and statistical agencies. 1 , 3 , 8 This Policy Inquiry centers specifically on UDS reporting and Medicaid data for 2 reasons. First, FQHCs are the primary federally designated safety-net providers for low-income, uninsured, and underserved populations, and their performance accountability flows directly through UDS, 9 making HRSA's removal of SOGI elements from required UDS reporting a first-order threat to equity monitoring in the communities where LGBT disparities are most concentrated. Second, Medicaid is the dominant payer for FQHC patients, 7 and CMS's June 2025 rescission of SOGI guidance removes a critical leverage point for requiring structured demographic data collection at the point of enrollment and care. No other pairing of federal reporting infrastructure and payer coverage reaches this population at comparable scale. When disparities are observable, systems can set targets, monitor performance, and trigger corrective action; when they are not, inequity becomes administratively invisible. Safety-net systems that cannot disaggregate outcomes by SO have no denominator for equity accountability; the disparity exists in the population but disappears from the administrative record. The same logic applies with equal force to GI data: without structured collection of GI measures, transgender and gender-expansive patients become administratively invisible, and systems lose the capacity to monitor or close disparities for that population as well. This Policy Inquiry translates published evidence from the Whole PERSON Health Score (WPHS) framework and subsequent safety-net analyses of SO disparities in whole-person health. It does not present new quantitative estimates; it re-contextualizes published results and pairs them with community sensemaking to generate actionable recommendations. Throughout this Policy Inquiry, we use “LGB+” when referring specifically to findings from the WPHS safety-net analysis, which measured SOGI; we use “LGBT” or “SOGI” when referring to the federal policy environment and recommendations, which concern both SOGI. Evidence base and approach The WPHS provides a whole-person screening framework that measures nonmedical determinants of health, including housing, food security, financial strain, transportation, and social support, along with clinical health domains such as depression and functional status. 10 Unlike tools such as PRAPARE or the AHC-HRSN screening tool, which focus primarily on social needs, the WPHS integrates clinical health domains - physical health, emotional health, and resource utilization - alongside socioeconomic, behavioral, and lifestyle domains within a single 28-item composite framework; letter grades calibrated to anticipated impact on life expectancy enable prioritization across the full spectrum of nonmedical determinants simultaneously, rather than screening for social needs alone. 10 The WPHS was developed and validated in a safety-net Medicaid context, producing structured, multi-domain, patient-level screening data: the type UDS equity reporting requires. That alignment is the primary rationale for drawing on WPHS data here. HRSA's removal of SOGI elements from required UDS reporting forecloses exactly this kind of equity monitoring at the institutional level. The published WPHS safety-net analysis documents disparities by SO; it does not include a separate measure of GI or transgender status, a limitation of the current evidence base discussed below. 11 A companion analysis examining whole-person health disparities among transgender and gender-diverse patients in the same safety-net dataset is currently in preparation; together, these studies will provide a more complete picture of SOGI-disaggregated disparities within this population. Parallel analysis disaggregated by GI remains an important gap in the published literature more broadly. To incorporate community interpretation and stress-test policy implications, we conducted illustrative interviews with 7 LGB+ adults over Zoom. Participants were recruited through purposive outreach to LGBT community organizations and networks across multiple US cities to reflect variation in age, race, gender, and geography; the sample is intentionally illustrative rather than statistically representative. In each interview, we presented published findings from the WPHS safety-net analysis and asked participants to respond to the patterns and identify implementation priorities. The goal was to test whether quantitative findings resonated with lived experience and to surface operational concerns that survey data cannot capture, not to generate new empirical claims. The Zoom format was selected to enable geographic reach across diverse participant locations within the constraints of a non-research policy inquiry. All participant names used herein are pseudonyms. These interviews were conducted as a non-research policy inquiry and did not require IRB review. The primary limitation of this approach is the small, non-probability sample; interview material is used throughout to contextualize and interpret quantitative patterns, not to generalize. A companion manuscript currently under review examines the specific consequences of SOGI data gaps for equity monitoring in HIV prevention, using PrEP uptake as a use case; that analysis builds on the denominator-loss framework developed here and provides applied evidence for the argument that SOGI data removal produces measurable gaps in equity accountability. Generational reversal as a targeting signal Published whole-person screening evidence indicates LGB+ disparities are not uniform across the life course. 11 Older LGB+ adults approach parity with heterosexual peers for some outcomes, while younger cohorts experience compounding disparities that intensify in successively younger age groups (“generational reversal”). This pattern holds across multiple domains: depression rates are highest in the 18-25 cohort and diminish with age, and parallel age gradients appear in food insecurity, financial hardship, and transportation barriers—suggesting the generational reversal is not an artifact of a single outcome but a structural signal embedded across the whole-person screening framework. 11-14 Figure 1 summarizes these age-stratified marginal effects for selected outcomes. We interpret this pattern as consistent with survivor selection and evolving structural discrimination (eg, occupational sorting, constrained wealth transfer, and minority stress), rather than as evidence that younger generations are adequately served by existing legal protections. For safety-net systems, the policy implication is straightforward: equity governance and operational investments should prioritize the younger cohorts where disparity concentration is greatest. Neutral care isn’t equitable care This matters for policy because “non-discriminatory” care is not the same as equitable care. In 1 study, 34% of LGBTQ+ patients reported affirming care, 60% reported neutral care, and 6% reported discriminatory care; compared with affirming care, neutral care was associated with a 12.4 percentage-point lower likelihood of ever having been tested for HIV and a 17.1 percentage-point lower likelihood of recent HIV testing, while discriminatory care was associated with a 12.2 percentage-point lower likelihood of recent influenza vaccination and a 14.8 percentage-point lower likelihood of recent colorectal cancer screening. 15 For safety-net leaders and policymakers, this reframes “experience of care” from a soft outcome to a lever for preventive service delivery and downstream cost. Operationally, moving patients from neutral to affirming care requires specific, measurable actions: LGBTQ+-inclusive staff training tied to competency verification, 16 structured patient experience questions disaggregated by SOGI in quality measurement dashboards, and provider accountability linked to affirming care rates as a performance metric and not a standalone sensitivity training. 17 The education paradox (policy levers) The “education paradox” is a governance problem for safety-net systems and policymakers: LGB+ adults can be more credentialed than heterosexual peers yet still experience higher material hardship and worse functional health, meaning education-only solutions are unlikely to close equity gaps. 18 In our published safety-net analysis, LGB+ individuals outperformed heterosexual peers in educational attainment by 11-22 percentage points yet had worse outcomes across multiple social and health domains. 11 External evidence corroborates this: 47% of LGBTQ employees report lifetime workplace discrimination (up from 38% in 2011), and LGBTQ+ workers earn approximately 90 cents per dollar compared to their non-LGBTQ+ counterparts, underscoring that credentials do not reliably translate into security under conditions of structural discrimination. 19 , 20 Four mechanisms help explain the credential-to-security gap and each mechanism points to a different policy lever. First, workplace discrimination and wage penalties persist despite credentials, limiting the returns to education. 18 , 21 Second, occupational segregation channels LGB+ workers toward “safer” industries with lower pay and fewer benefits. Arthur (pseudonym), a 59-year-old gay man from Pittsburgh, described this sorting: “ As far as career paths where I was guaranteed some sort of acceptance, I could go into the restaurant industry. I could be a florist. I could do hair. ” Research confirms LGB+ workers are overrepresented in low-wage service sectors that offer perceived safety from discrimination but trap workers in precarious employment with limited benefits and advancement. 22 , 23 Third, reduced family financial support and constrained intergenerational wealth transfer limit household “shock absorbers” during economic crises. 24 Fourth, minority stress can undermine employment continuity and reinforce a cycle of precarious work, weaker benefits, and worsening health. 25-27 The divergence between structural reality and personal narrative is policy-relevant: Arjun (pseudonym), a 29-year-old gay man with a college degree, easily connected minority stress to his mental health, “ I started drinking heavily because it was difficult to accept that I was gay… missing work and it affected my finances, leading to more depression ”—yet when asked what stressed him out, he said: “ Not being gay. That ship has sailed. Work. Money. Just adult things in general. ” This divergence shows how cultural acceptance can mask structural inequity: when individuals stop connecting hardship to identity, the political pressure for systemic reform weakens. The implication for policymakers is that waiting for affected communities to self-identify and advocate may not be sufficient—the accountability burden sits with systems, not individuals. The survivor bias trap Apparent improvement in outcomes among older LGB+ adults can mislead policymakers into underinvesting in younger cohorts and misreading inequity as “resilience”; this is a classic survivor selection and measurement problem with direct implications for how safety-net systems set priorities and targets. 28 , 29 Colleen (pseudonym), a 61-year-old queer Black artist, captured the coexistence of progress and trauma in her cohort. On one hand, she described her current freedom, “ I kind of love that I’m in the springtime of my elderhood… It's wonderful. It's very liberating, ” and recalled seeing services and rights expand over time. Yet the AIDS crisis fundamentally shaped her cohort's lived experience and who survived to be measured. As of 2023, cumulative deaths among people with AIDS in the US stand at 771 864. 30 Colleen described this attrition in human terms: “ [It] was a pretty brutal thing… all your friends dying around you… Nursing them… Going to multiple funerals… ” Those most severely impacted by discrimination, violence, and the AIDS epidemic are absent from any health survey—and their absence biases any generational comparison toward apparent resilience. The “resilience through adversity” narrative risks 2 policy errors: it treats selective survival as evidence that systems worked, and it naturalizes discrimination as character-building rather than preventable harm. Longitudinal work on LGBTQ older adults emphasizes the role of social bonds, community connection, and shifting social context, factors shaped by policy and institutions, not only individual traits. 31-33 Notably, sociopolitical involvement, such as, activism, civic participation, and engagement with affirming community organizations, is among the strongest drivers of wellbeing for LGB+ individuals, a finding with direct implications for how safety-net systems should structure community partnerships. 34 Beyond brochures: turning screening into action Routine SOGI collection and whole-person screening create the measurement needed for equity, but policy value comes only when systems attach accountability and an operational response to screening results. Prior work in safety-net settings has shown that SOGI data and whole-person screening can identify disparities that would otherwise be invisible; the question for policymakers and safety-net leaders is what mechanisms convert that visibility into action (workflows, staffing, contracting, and performance monitoring). 11 , 35-37 When whole-person screening flags housing instability, food insecurity, or financial strain, the response cannot be a passive referral list. Safety-net systems should build protocols that trigger warm handoffs: real-time introductions (in-person or virtual) to benefits navigators, community health workers, or legal aid partners, so that screening results reliably produce service connection. 38 In 1 quality-improvement initiative, warm handoff rates increased from a monthly median of 11%-24% during the intervention period. 39 Evidence from integrated/telehealth warm-handoff models similarly shows higher referral acceptance and greater engagement compared with usual referral processes. 40 Partnerships should be structured as embedded capacity, not “community resources” handed out at discharge. Existing models demonstrate this is operationally feasible: New York's Legal Aid Society LGBTQ+ Law and Policy Unit provides housing discrimination defense and eviction protection that can be triggered directly by screening results. Medicaid agencies can require or incentivize managed care organizations to provide LGBTQ+ care navigation functions, and organizations can formalize agreements that allow navigators to schedule appointments, manage authorizations, and connect patients to affirming providers across systems. 41 What policymakers can do now The education paradox implies that expanding college access alone will not close LGB+ economic gaps when labor-market discrimination converts credentials into insecure work. The education paradox reflects a labor-market failure: credentials do not reliably convert into economic security under conditions of structural discrimination. Workforce policy, therefore, is health equity policy. Safety-net systems and their public funders should treat workforce partnerships as an accountability mechanism, limiting referral pipelines to employers and training programs that meet verifiable non-discrimination and benefits standards. Evidence supports this: employment non-discrimination protections produce spillover effects within firms—increasing board diversity and embedding equity norms in governance practices, consistent with norm diffusion after such policies are adopted. 42 , 43 Policy response must operate at the points where systems allocate resources and set accountability: contracting, funding conditions, performance measurement, and operational workflows. The recommendations below are calibrated to the current federal environment. EO14168, ongoing threats to federal funding for equity-focused programs, and risks of data weaponization all constrain what institutions can mandate and what patients may safely disclose. Where recommendations apply specifically to a particular actor, this is noted explicitly; safety-net leaders, Medicaid agencies and managed care organizations, and local governments each have distinct but complementary levers. Make anti-discrimination implementation a condition of public dollars (safety-net leaders, state Medicaid agencies, local governments) Tie workforce development grants, economic development incentives, and public contracts to documented implementation, not merely existence, of non-discrimination and anti-retaliation policies, with public reporting requirements and financial consequences for noncompliance (consistent with evidence that formal legal recognition produces downstream health and economic benefits). 42 , 44 Fund healthcare-to-workforce pipelines inside safety-net systems (safety-net leaders, Medicaid managed care organizations) Resource embedded navigators who can respond to screening results and execute warm handoffs to vetted workforce programs and employers, with explicit metrics (handoff completion; placement/retention at 6-12 months; changes in material-hardship indicators). Contract with community organizations as health infrastructure (safety-net leaders, Medicaid agencies) Use multi-year contracts (not short-cycle grants) for navigation and closed-loop referral functions, with measurable capacity expectations (time-to-first-contact; caseloads; referral completion). Given that sociopolitical involvement is a primary driver of LGB+ wellbeing, these organizations are not merely referral conveniences, they are health infrastructure. Mandate SOGI data integration with enforceable accountability (safety-net leaders, state Medicaid agencies, MCOs) Set targets for structured SOGI completion and track performance routinely via quarterly dashboards tied to quality improvement goals and, where feasible, payment incentives. Where completion targets are not met, corrective action plans should be required, with withheld quality bonus payments and public reporting as escalating consequences. Patient willingness is not the limiting factor nearly 80% of adults were willing to report SOGI information in a digital registration context 45 and implementation hinges on leadership support, workflow standardization, and structured electronic health record (EHR) fields. 46-48 Do not collapse GI into SO; collect them separately. Implementation requires attention to privacy protections and community trust. Given the risk that SOGI data could be weaponized in the current political environment, institutions must pair collection mandates with explicit data governance policies, restricting access, prohibiting downstream disclosure to law enforcement or federal agencies, and communicating these protections directly to patients. Chilling effects on disclosure are real and documented; community trust is a precondition for data quality, not an afterthought. 46 , 48 , 49 Safety-net leaders should engage LGBTQ+ community organizations in designing and communicating data governance policies before expanding SOGI collection, particularly in jurisdictions where anti-LGBTQ+ enforcement activity is elevated. The urgency is generational The “generational reversal” pattern: worse outcomes among younger LGB+ adults despite greater legal protections and cultural acceptance, should be treated as a policy warning, not a paradox. It suggests that structural disadvantage persists even as overt stigma declines, in part through mechanisms that are harder to see and harder to litigate: subtle bias, occupational sorting, and wealth transfer denial. 18 , 21 , 24 The Arjun example illustrates the systemic risk: when affected individuals cannot connect their structural circumstances to their identity, the political signal that typically drives reform goes quiet. Safety-net systems and policymakers cannot wait for perfect longitudinal attribution before acting, because the governance problem is already clear: higher educational attainment without economic security, higher health awareness alongside worse outcomes, and screening that identifies need without consistent, accountable response. Whole-person screening infrastructure can surface these disparities, but only if systems preserve SOGI measurement and build operational pathways that reliably convert “flagged need” into services, protections, and follow-up. Protecting SOGI denominators means maintaining structured SOGI fields in EHR systems and setting completion targets tracked via quarterly dashboards, but it also requires pairing collection with data governance frameworks that explicitly prohibit downstream disclosure and communicate those protections directly to patients. In the current federal environment, where EO14168 has eliminated GI measures from hundreds of federal data collections and SO removals are spreading beyond the order's explicit mandate, this denominator protection function shifts to safety-net institutions themselves: FQHCs, Medicaid managed care organizations, and state health agencies that retain independent authority over their own data systems. Embedding warm-handoff workflows, as detailed in the Beyond Brochures section, means ensuring those protocols are activated at the moment of screening, not deferred to discharge, with completion rates tracked on the same dashboard as screening volumes. And contracting and procurement leverage operates through 3 specific mechanisms: conditioning public contracts and workforce-development grants on documented, not merely stated, non-discrimination implementation with public reporting and financial consequences for noncompliance; requiring managed care organizations to include LGBTQ+ care navigation as a covered contractual function with measurable deliverables: time-to-first-contact, referral completion, placement retention at 6 and 12 months; and replacing short-cycle grants to community organizations with multi-year service agreements structured around capacity expectations rather than activity counts. These recommendations do not require new federal authorization. They operate through administrative and contractual authority that safety-net leaders, Medicaid agencies, and local governments already hold—authority that matters more now that federal accountability mechanisms have been withdrawn. Supplementary Material qxag124_Supplementary_Data qxag124_supplementary_data.zip (60.7KB, zip) Acknowledgments The authors thank Anthony Firek, Geoffrey Leung, Maryah Garner, Brittany Bass, and Bijan Sasaninia for their work on the whole-person health screening and sexual orientation disparities studies whose foundational work made this policy inquiry possible. The authors are also grateful to the LGBTQ+ community members who shared their experiences and helped contextualize the policy implications of this work. The authors thank the anonymous reviewer whose constructive comments strengthened the policy discussion and improved the manuscript. All interview participant names are pseudonyms. Interviews were conducted as a non-research policy inquiry in which published findings were presented to 7 LGB+ adults and reactions were elicited to inform implementation priorities. No new empirical claims are derived from these interviews. IRB review was not required. Contributor Information Dhruv Khurana, Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States. Andrew Short, Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095, United States. Supplementary material Supplementary material is available at Health Affairs Scholar online. Funding None. Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials. The authors declare no conflict of interest. This policy inquiry draws on the authors’ previously published work on whole-person health screening and sexual orientation and gender identity disparities in safety-net settings. Notes 1. Bouton  L, Redfield  E. Removal of sexual orientation and gender identity from federal data collections. Williams Institute. Accessed May 10, 2026. https://williamsinstitute.law.ucla.edu/publications/sogi-data-collection-removal/ 2. 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