Before the Affordable Care Act, it wasn't unusual for people in the LGBT community to be locked out of health insurance. Insurers could legally deny coverage based on a person's sexual orientation, gender identity, or pre-existing health condition.
"It was everything from trans men and women being denied health coverage because their health history was confusing to a hospital or an insurance company, to young LGBT people not being able to afford coverage," said Brian Sims, a Pennsylvania state representative, lawyer, and LGBT civil rights activist.
But since the launch of the ACA, things have changed. Insurers can no longer deny anyone free preventive coverage because of their sexual orientation, gender identity, or gender expression. Moreover, legally married same-sex couples can buy a marketplace plan even if they live in a state that doesn't recognize same-sex marriage.
And, of course, pre-existing conditions no longer matter.
"These are historic new protections," said Sims, a Democrat representing Philadelphia's 182d District in Center City. "Not being denied coverage because of a pre-existing condition does impact the LGBT community, there is no question about it."
A recent Urban Institute Health Reform Monitoring Survey found the number of lesbian, gay, and bisexual people without insurance has been sliced almost in half in less than two years.
In the four months leading up to the first open enrollment period on Oct. 1, 2013, 21.7 percent of the LGB community (transgender people were not included) was uninsured, according to the survey. When the marketplace closed on March 15 this year, that was down to 11.1 percent.
According to the survey, almost all of those insured had incomes that either fell below 138 percent of the federal poverty level and qualified for Medicaid or were eligible for marketplace tax credit subsidies.
"The big grand message about enrolling in the ACA was critically important and it got lot of those people who were listening to it," Sims said. "But it clearly didn't get everybody."
Though the survey didn't include transgender people, Sims said they and African Americans were the LGBT community's "most at-risk populations that we're still not getting to."
"If somebody asked you how are things in America for the LGBT community and you say they are great or they are getting better, it means that you are not paying attention to what is happening to communities of color or the trans community right now," Sims said.
For instance, he said, a post-operative trans woman may be more susceptible to certain types of cancers because of hormone therapy.
"If you are a trans woman, you deserve the same kind of health care as everyone else," he said.
But young people, African Americans, and the transgendered are often among the poorest in the LGBT community, said Jay Evans, development director for Equality Pennsylvania, a statewide political action committee. So the cost of health insurance may be part of the reason they remain uninsured.
"Another thing is there is a distrust of different government programs and doctors," Evans said.
Sims believes the way to get that segment of the LGBT community covered is also the way to reach all people who are still uninsured - localize the message. People need to hear there is nothing unique about them that will stand in the way of getting insured.
"We need to get people to listen to more local messages, more community messages," he said. "It's important to talk specifically about how the ACA impacts the LGBT community. But it is also about how it impacts the Hispanic and Latino communities, how it impacts all the racial and ethnic minorities, and how it impacts women."
Sims said Philadelphia organizations such as the William Way LGBT Community Center and Mazzoni Center were helping to promote the ACA through programs and educational sessions. The rest may mean wearing down a little shoe leather.
"Philadelphia is a city that knows a thing or two about going door to door, community to community," Sims said. "We're a community that knows about getting a message out among all of our different communities within the city."