"Obama administration may add taxpayer-funded sex-change operations to ObamaCare, Medicare, Medicaid," warned an ominous headline on conservative news site LifeSiteNews late last year. Undoubtedly designed to strike terror into the hearts of readers already deeply worried about the pinko commie queer socialist connotations of the Affordable Care Act, the headline sounded like my version of utopia. (Though I prefer to call it gender confirmation surgery, not a sex-change.)
This and other arguments have been fueling conservative hatred against ACA, but it's worth taking a closer look at how much benefit ACA actually provides for trans people -- since the US doesn't exactly seem flooded with free transition care as of 1 January. In fact, the situation for trans people under ACA is quite complicated, and their ability to access care depends in large part on where they are, who their providers are, which plans they have, and how hard they're willing to fight for it.
ACA explicitly bans gender discrimination and the Department of Health and Human Services has clarified this to mean that: "...Section 1557's sex discrimination prohibition extends to claims of discrimination based on gender identity or failure to conform to stereotypical notions of masculinity or femininity." However, in practice, the enforcement of this clause has been left up to the states. A handful, including liberal pinko paradise California and its San Francisco values, have issued bulletins specifically requiring insurance plans to cover transition services. Others have remained silent on the subject.
This means that in many states, transgender people still can't access transition services, or access variable care depending on which health care plan they select. Herein lies a major flaw of ACA: under law, insurance companies can no longer discriminate against people on the basis of pre-existing conditions, but that doesn't mean they can't freely write policies to exclude certain kinds of treatment and care.
While being transgender isn't a medical condition in the sense that it means something is wrong with you and it needs to be fixed, treating it as one for legal purposes ensures that people can access transition services -- unless, of course, their insurers don't provide coverage for hormone therapy, gender confirmation surgery, transition-related plastic surgery, and more. Unfortunately, trans people are still required to demonstrate medical necessity for transition-related care under the framework of the current health care system, and insurers can feel free to deny claims they don't think meet the criteria of "necessity." Despite the vision of terror evoked by trans people running amok after receiving full transition care dredged up by conservatives, the fact is that relatively few trans people are able to transition through Obamacare.
They need to live in states that mandate care for transition, their providers need to be familiar with the paperwork ins and outs of handling transition and ensuring it gets covered, their plans need to cover it, and in many cases, they need to be willing to self-advocate. This can require months or years of appealing claims rejections, meeting with insurance representatives, and potentially working with attorneys on legal options for forcing insurers to provide what their customers are paying for. This is hardly a world in which the government is handing out a "sex-change" and a lollypop with every insurance card.
Furthermore, discrimination runs deeper than simply whether trans people can access transition services. In addition to needing transition-related care, many also have health care needs that are considered unique, and apparently confounding, to insurance companies. Women who need prostate exams and men who get cervical cancer aren't something such firms seem to know how to handle, and their response is often to deny care, despite the fact that this is a clear instance of discrimination.
Trans people and health care providers are already reporting problems when it comes to processing claims and providing care for people with health care conditions that don't appear to match the gender on their paperwork. If it's considered "transgender health care," patients may need to pay out of pocket, even if it has nothing to do with their gender identity; thus, a woman who gets prostate cancer might be paying for all her treatments herself, and a trans man with breast cancer could struggle to get care (though cis men get breast cancer as well!).
This creates a separate -- and unequal -- treatment for trans versus cis people in the health care system, where trans people are being denied care not just for their transition-related medical needs, but also other, unrelated conditions. While some of the historical inequality has been addressed, and insurance companies (theoretically) can't deny coverage to a trans person for something like a broken leg or liver cancer, that doesn't mean they can't find other methods of denying care.
Furthermore, there's a significant loophole in Obamacare that adversely affects the trans community, and it has to do with the way the insurance subsidies are handled, as Tara Murtha explains at RH Reality Check. In a nutshell, if you want the subsidy, you have to sign up through the state marketplace, and your gender markers across your documentation need to match: most critically, the gender on your health insurance and the gender on your Social Security account must be the same. If they aren't, you don't qualify.
Mismatched IDs are a common issue for members of the trans community because it's expensive and time-consuming to make changes, especially gender changes. The Social Security Administration only just recently lifted its requirement that people show proof of gender confirmation surgery to have the gender on their accounts changed, and the process still requires showing a doctor's letter and ID with the correct gender. For trans people early in transition who don't have a doctor's letter because, say, they were uninsured and couldn't get care, that means their Social Security cards may have the wrong gender marker.
Trans people are much more likely to live in poverty than cis people, with 15% earning less than $10,000. The unemployment rate for trans people is double that of cis people, and almost half of trans people are underemployed. Especially among the trans community of color, poverty is a particularly acute problem, and people are counting on these subsidies to access care. Without the subsidies, they can't afford insurance, and they certainly can't afford to pay out of pocket for procedures their insurers should be covering.
As has so long been the case, trans people are turning to black market hormones, sex work, and other options to manage and fund their transitions. Trans women of color in particular live in a precarious state. While it's one that can't be mitigated by a step as simple as creating equal access to insurance, it would be a step in the right direction.
ACA, in other words, is not a magic bullet for trans people. In many states, it's still more of the same for trans people, while in others, coverage options can be limited and may require an uphill battle. As a short-term solution, the federal government needs to issue clear and unambiguous anti-discrimination guidelines that include a mandate to cover all transition-related procedures as well as any and all medical care needed regardless as to whether it aligns with the gender on health insurance policies. Trans people are policyholders like everyone else and should receive the benefits to which they are entitled.
In the long term, of course, I'd love to see ACA replaced with an actual national health system with a nondiscriminatory structure -- but I'm not holding my breath on that one.