As the Republican-dominated federal government bickers about how to repeal and replace the Affordable Care Act (ACA), concerns about losing both healthcare and protection from discrimination are rising in the transgender community.
When asked if anybody was afraid of losing coverage if Obamacare is repealed, several people at the February support meeting of the Gender Alliance for the South Sound (GASS) said, “Who isn’t?” GASS is a confidential, Tacoma-based organization that supports local transgender people. The group offers a space to discuss the process of transitioning, to offer solidarity, and to feel accepted and validated. At the mention of health care coverage, several people explained that Obamacare is crucial to their ability to access the care they need.
Until July of 2016, when Section 1557 of the ACA came into effect, trans people had little protection from discrimination. This provision specifies that, “individuals must be treated consistent with their gender identity, including in access to facilities,” making healthcare more attainable for many trans people.
Without this anti-discrimination policy, many trans people struggled to get insurance companies to cover their medical needs. In a small, local survey conducted by this reporter, participants described instances of gender-based discrimination by healthcare providers. One trans woman said that until the non-discrimination clarification, Apple Health denied coverage of her hormone replacement therapy (HRT), which is a part of medical gender transition. Another respondent wrote, “Most healthcare providers do not know much about transgender people, and many would prefer to find other patients than to learn. Of course, the lack of hard information makes it difficult. There needs to be more research and more material for MD’s [sic] to learn from.”
These experiences echo the national data. According to the National Transgender Discrimination Survey Report on Health and Health Care, survey participants reported, “very high levels of postponing medical care when sick or injured due to discrimination (28%) or inability to afford it (48%),” and, “50% […] reported having to teach their medical providers about transgender care.”
Transition-related medicine is an important part of treating the dysphoria many (though not all) transgender people experience. According to the American Psychiatric Association, gender dysphoria, “involves a conflict between a person’s physical or assigned gender and the gender with which [the person] identifies.” Gender-confirming medical treatment can reduce or eliminate gender dysphoria which can be a major barrier to living a full, happy, and healthy life. However, despite the importance of medical transition for many trans people, it is not a part of most medical school education programs, and many insurance companies prefer to see hormone replacement therapy and gender-confirming surgeries as non-essential.
Some practitioners, however, are working to support trans patients. “I would often see [trans patients] pro bono,” said Julie Dybbro, an ARNP, hormone expert, and owner of Complete Women’s Health Care in Olympia. “Oftentimes they were homeless, they didn’t have any money. I’d give them samples, I’d do whatever I could, but when insurance started paying, all the sudden it was a viable part of my practice.”
In addition to the fear of losing both healthcare and protection from discrimination, many members of the trans community are now worried about a leaked draft of a “religious freedom” executive order that may allow providers to refuse care based on religious belief.
Nancy Armstrong, an ARNP in Olympia, expressed concern that religious freedom legislation would allow providers to deny patients care. “There are people who are really uncomfortable with [treating trans and gender nonconforming people],” said Armstrong. “I’ve been a nurse for thirty-six years and I was never taught that way. I took care of people no matter what.”
Trans individuals are more likely to experience gender-based discrimination in medical settings than cis (non-trans) people. In the same local survey, 56% of trans participants reported facing discrimination based on gender identity compared to 20% of cis people. All of that 20% were women who reported experiencing sexism.
However, some clinics, like the Rainbow Health Center in Olympia, actively seek to be welcoming. This is evidenced by the rainbow flag flying on the front of the building. It’s impossible to miss from 4th Avenue.
Dr. Matt Goldenberg, a clinical psychologist who works in the Rainbow Health Center, makes it a priority to accept Medicare and Medicaid. “As a provider,” Goldenberg said, “that’s a commitment I make to make sure that I’m seeing people who may not be eligible for service anywhere else.” Many providers don’t take Medicaid and Medicare which have much lower reimbursement rates than other insurance. “From a business perspective, there’s not much incentive to take half a payment for the same work,” Goldenberg explained, “but from a social justice perspective, it is really important to do it.”
Dr. Goldenberg also co-owns ReLearn LLC whose mission is, “to build safer and more inclusive environments by training and educating healthcare professionals, employers, parents, and educators about gender identity and gender bias.”
Many providers are determined to continue serving trans patients. “If Obamacare gets repealed,” said Dybbro, “I’m going to have to get very creative again. We’ve been there before, and we’ll figure it out.”
Kit Gertje is a recent graduate from the Evergreen State College and a nonbinary member of the Olympia LGBTQIA+ community. They graduated in March 2017 with a degree in Communications.
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