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

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.