How Obamacare Will Affect Trans Folks and Families

After I wrote recently about how Obamacare will affect LGBT people and their families, I received a number of comments asking about how new health care regulations will specifically affect the trans community. I turned to Anand Kalra, Project Health program manager at the Transgender Law Center in Oakland, Calif., to get answers.

The Advocate: Will Obamacare make things better for trans folks? Specifically how?
Anand Kalra: Yes. First, the Affordable Care Act opens the door to coverage for a group of people that have been held outside. The ACA makes it illegal for an insurance company to refuse to sell an insurance plan to someone because they have "pre-existing conditions." Historically, health insurance companies have considered gender identity disorder, the psychiatric diagnosis used to enable access to transition-related care, such as hormone replacement therapy, a pre-existing condition. So, if anywhere in your medical record you had been diagnosed with GID, an insurance company could use that against you, and refuse to insure you. Starting on January 1, 2014, that practice is prohibited for any diagnosis, including gender identity disorder.

Second, the ACA provides options in care for vulnerable populations. In states that are adopting the Medicaid expansion, low-income single adults without qualifying disabilities will now be eligible for Medicaid programs; additionally, the Medicaid program's income limits have been raised. So a person making up to 138% the federal poverty level (about $15,800 for individuals, $32,000 for a family of four), will be able to have coverage.

There are also assistance available for many individuals and families who are low-income, but earn too much to qualify for Medicaid (or whose state is not participating in Medicaid expansion). For people making between 138% and 400% of the federal poverty level (or people making more than 100% of the federal poverty level in states not participating in Medicaid expansion), subsidies are available to offset the monthly and out-of-pocket costs of insurance plans purchased through the state exchanges.

The system isn't perfect -- low-income people buying insurance through a state exchange will still have to pay monthly fees -- but it's an improvement over the current setup, especially since all plans sold through state exchanges have to provide coverage for 10 "Essential Health Benefits," which include, among others, preventative care, reproductive health, prescription drugs, mental health care, and treatment for substance abuse.

Third, the nondiscrimination section of the Affordable Care Act, coupled with federal health regulations that prohibit discrimination in the administration of any program that receives federal funding, has made big waves. The regulations specifically protect people from discrimination based on gender identity, in addition to a number of other categories, at the level of benefit administration. Is this an explicit mandate that insurance companies nationwide must pay for transition-related care in all health care plans? No. However, we believe that these nondiscrimination protections mean that a transgender person who is covered under a plan purchased through any state exchange, or any Medicaid plan, has the right to appeal any denial they receive from their insurance carrier that targets them as transgender people. For example, if an insurance plan covers hormone replacement therapy for, say, women in menopause, then selectively denying coverage for hormone therapy to a transgender person should constitute discrimination. If this happens (and we anticipate it will), people have the right to file a formal complaint with the Office of Civil Rights with the U.S. Department of Health and Human Services, who will investigate the claim.

These nondiscrimination protections apply not just to health insurance, but also to any health care setting that receives federal funding (and most do). The 2012 "Injustice at Every Turn" report of the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 19% of the 6,500 transgender people they surveyed had been refused medical care because they were transgender. Put another way, nearly one in five transgender people have been told by health workers that they are unworthy of care--from bronchitis to broken bones. Moreover, it's all too common that health care providers inexperienced in working with transgender clients probe with irrelevant questions and show a gossipy fascination with transgender people's genitals, even when the care they require has nothing to do with transition. Twenty-five percent of the sample from "Injustice at Every Turn" reported being harassed or disrespected in a doctor's office or hospital. Previously, these injustices could go on with no recourse, and while we can't prevent them from happening with law alone, transgender people now have the right to report discrimination in health care and to have their experiences taken seriously.

What won't Obamacare do for trans folks? Were there provisions left out of the bill that would have helped trans folks?
Sadly, we are still at a point where we have to justify that trans-specific health care is "medically necessary," and insurance companies still resist covering treatments that are recognized by specialists to be vital and medically necessary for some individuals arguing that these procedures are purely "cosmetic," such as facial feminization surgery and electrolysis for transgender women. From my perspective, these procedures could be lifesaving for some transgender women, who are at extremely high risk of interpersonal violence.

Can you tell me about the demographics of the trans community? Are they disproportionately without health insurance?
I know the broader gay and lesbian community is, according to the Williams Institute. Overall, we know that trans people face immense discrimination in employment -- from hiring to promotion and termination--so transgender people are unemployed at a disproportionate rate. In addition, many transgender people lose support from their families and friends when they choose to live authentically, which results in being socially isolated, and therefore more likely to lack a safety net when hard times strike. As a result of these compounded issues, many transgender people live in poverty and work in occupations that offer little protection and no benefits.

What about states that aren't providing Medicaid expansions -- will this adversely impact the trans community?
States that are opting out of the Medicaid expansions are leaving hundreds of thousands of people vulnerable, including transgender people. We expect group of transgender people who could benefit the most from the Affordable Care Act are those who would be newly eligible for Medicaid because of the increased income limits and new access for single adults. People in states who are opting out of Medicaid expansion will continue to exist, and continue to struggle to afford the health care that every human being deserves.

What can the trans community do beyond Obamacare to ensure its health and well-being?
We're facing an uphill battle, and we've got to keep marching. We've got to keep coming out, keep connecting with each other to form and maintain our communities, and keep advocating for systemic change.