Beyond Visibility: Building a Health System that Supports Trans Lives
Every year on March 31, people observe International Transgender Day of Visibility to honor strides made for trans and non-binary (TNB) people across the world, while also recognizing the continued challenges and threats to their basic rights. This year, as health advocates, we are celebrating the increased access to gender-affirming care for TNB people under the Affordable Care Act (ACA), but also calling attention to the latest attempts by the Trump administration to undo this progress.
This week, the Department of Justice broadened its already-hostile stance against the ACA, telling a Federal Appeals Court that a December ruling by a federal district judge in Texas deeming the law unconstitutional should be upheld in its entirety. Most legal scholars who have scrutinized the ruling have found its logic to be tortured, suggesting it was politically motivated. Should the Trump administration succeed in its latest attempt to dismantle the ACA, it would turn back the clock on TNB rights and access to quality, affordable health care since the law’s passage and implementation.
Coverage gains disproportionately benefit TNB people, especially TNB people of color.
TNB people often report significant social challenges linked to adverse health and mental health outcomes, including high rates of gender-related housing discrimination, employment discrimination, familial rejection, harassment, abuse and poverty. Transgender people are two to four times as likely to live in poverty than the general population. For TNB people of color, the rates are even higher with approximately 40 percent of Black, Latinx and Indigenous TNB people experiencing poverty. Because trans and non-binary people are more likely to live in poverty than their cisgender peers, they were disproportionately represented in the millions of people newly receiving coverage through the ACA’s marketplace and Medicaid expansion.
TNB people are still uninsured at higher rates than the general population, but a 2017 study found that coverage for TNB individuals increased by 5 percentage points between 2011 and 2015, following the ACA’s implementation. While we still have a long way to go to ensure all TNB people have access to care, these coverage gains ensured more low-income TNB people than ever could access life-saving treatment, including gender-affirming care and transition-related services shown to improve health and mental health outcomes.
The ACA expands consumer protections to prohibit discrimination against TNB people.
TNB people face significant discrimination when navigating the health care system. According to the 2015 United States Transgender Survey (USTS) of over 27,000 TNB adults, one in three TNB people report negative experiences with their health care provider, including explicit discrimination and refusal of treatment, verbal harassment, and having to educate their provider about their health care needs. TNB people of color often face worse health outcomes than their white peers as experiences of discrimination in the health system are compounded by racism.
Although access to medical transition services are linked to improved mental health outcomes and quality of life, one in four TNB people reported being denied coverage for hormone replacement therapy and over 50 percent were denied access to transition-related surgery. Over one-third of TNB people cite discrimination in the health care system as a principal reason for delaying care or putting it off altogether, increasing their risk for adverse health outcomes and chronic illness.
Section 1557 of the ACA expanded consumer protection to TNB people by prohibiting discrimination on the basis of sex, defined by gender identity, for all health programs included in state and federal marketplaces as well as health programs and activities that receive federal funding. This means insurance companies can no longer deny sex-specific preventive services to TNB people, and TNB people can legally challenge denial of gender-affirming coverage. However, the Trump administration has attempted to undermine these gains by proposing an overhaul to Section 1557 and a rule change that would define gender as the sex assigned at birth.
The ACA strengthens access to mental health services, including substance use treatment.
Data from the USTS suggest that over 50 percent of TNB respondents experienced verbal harassment in the last year while one in ten were physically assaulted. These experiences of violence as well as other forms of rejection, social isolation and abuse are associated with significant mental health disparities. TNB rates of depression, anxiety and post-traumatic stress disorder are significantly higher than in the general population, and study after study shows staggering rates of TNB suicidal ideation ranging from 30 to 81 percent. Often TNB people use substances to cope with stress and trauma related to their experiences of violence, leading to higher rates of substance use disorders.
For TNB people of color who are criminalized for drug use at higher rates than white people, this leads to disproportionate representation of TNB people of color in prison. TNB people of color and specifically trans-feminine people of color are also at higher risk of violence and abuse, leading to worse health outcomes and significantly lower life expectancy. Although primary prevention of these health inequities requires us to societally address transphobia and racism across institutions and communities, the ACA made significant strides in expanding access to mental health and substance use treatment by strengthening mental health parity, including substance use treatment in the essential health benefits, and establishing a National Prevention Strategy with dedicated funding.
The work ahead: More than just ‘visibility.’
Despite the progress made since the ACA was signed into law, TNB people still lack access to quality, comprehensive, affordable, gender-affirming care, and the Trump administration continues its attempts to undermine TNB protections. In addition to the challenges highlighted above, lack of provider competency related to TNB health creates barriers to needed health and mental health services, and TNB people are three times more likely than their cisgender peers to travel 50 miles or more to access the health care they need.
At Community Catalyst, our mission is to ensure all consumer voices are heard wherever decisions about their health care are being made, and we know our partners on the ground share a commitment to this goal. A recent report by the CDC found that nearly two percent of high school students identify as transgender – that’s one in 50 kids. As health advocates, our fight for better health care should ensure a better future for TNB people.
On International Trans Day of Visibility and beyond, join us in this fight by supporting legislation to protect the ACA in court, continuing to advocate for state-level protections for trans and non-binary people (like the major Medicaid victory we recently saw in Iowa), prioritizing partnerships with state and community TNB-led organizations and coalitions, and elevating the voices and stories of TNB people, especially TNB people of color, in the fight for health justice.