March 31marks International Transgender Day of Visibility, which is an annual day of awareness that celebrates the accomplishments of transgender and gender non-binary (TNB) people. It also is an opportunity to elevate and advocate for change that would advance transgender justice. Health care for TNB people made strides under the Affordable Care Act (ACA) and its Medicaid expansion by reducing the rate of uninsured TNB people, improving access to gender-affirming care and expanding mental health and substance use treatment. It is important to continue to push for Medicaid expansion to include protections for TNB people and ensure access to comprehensive and equitable health care.
For instance, creating robust laws for coverage of transition-related care through Medicaid is a crucial step. The Movement Advancement Project has created a tracker which outlines the dire status of Medicaid policies regarding transition care by state. Of the 50 states and the District of Columbia, there are only 34 states that have transition-related health care coverage for gender-affirming hormone therapy. Grievously, gender-affirming surgery is even less likely to be covered, with only 25 states covering it, 22 that do not, and coverage being “indeterminate” in four states. It is important that advocates not only push for coverage of transition-related care through Medicaid, but for there to be specific policies outlining the right to receive this care, combating recent detrimental attacks on gender affirming care for trans youth.
There is also more to be done to protect the rights of TNB people under Section 1557 of the Affordable Care Act. Section 1557 established broad civil rights protections in health care, barring discrimination based on race, color, national origin, sex, age or disability in ‘any health program or activity’ that receives federal financial assistance. Under Section 1557, all health programs or activities administered by HHS itself (via the Centers for Medicare & Medicaid Services or the Substance Abuse and Mental Health Services Administration) are prohibited from discriminating in health insurance or health coverage. In 2016, the Obama administration’s interpretation of the statute required health care providers and insurers to provide and cover medically appropriate treatment for transgender patients, including hormone treatment, cancer screening, and surgeries. The law also relied on a broad understanding of gender identity, which included gender expression and transgender status. The Trump administration’s reinterpretation of this section defined “sex” to mean gender assigned at birth, excluding transgender people from the law’s umbrella of protection and threatened their access to care. Over the past year, the Biden administration has been working to reverse the Trump administration’s policy, and has essentially restored the original intent of the legislation.
Although the definition of sex has been reversed in Section 1557, it is important for these laws to be followed with enforcement and in-practice policies that are affirming, inclusive, and culturally competent. TNB people are a high-risk population for mental and physical health problems and are consistently and systemically underserved by the American health care system. This includes regular harassment and discrimination which contribute to high rates of stress and poorer health outcomes among TNB individuals. These very present barriers sway TNB people from accessing care due to fear of discrimination and refusal of care.
TNB fear and experiences of discrimination have been linked to high rates of post-traumatic stress disorder, lack of body satisfaction, depression, anxiety, and psychological distress. According to the Center for American Progress’s (CAP) analysis of the 2019 Behavioral Risk Factor Surveillance System (BRFSS) data, three in five transgender respondents reported having experienced poor mental health “at least one day in the past month.” Findings also show that transgender adults are more than two times as likely as cisgender adults to be told they have a depressive disorder. Isolation during the pandemic has also been significantly damaging to the mental health of TNB populations with one in three reporting having suicidal thoughts during the pandemic. TNB experiences of discrimination have also been extensively linked to high rates of substance use. In fact, transgender individuals who report high levels of discrimination are 3.59 times more likely to engage in binge drinking than those who report low levels of discrimination.
Though the Affordable Care Act expanded access to treatment for mental illness and substance use disorders, it is vital for TNB people to feel comfortable with accessing these services. It is therefore important for hospitals, clinics and doctor’s offices to be safe environments where people are given the medical care that they need. Even when providers do not deny TNB people care outright, they may verbally abuse or physically or emotionally harm their patients. Refusals and discrimination are even more present for TNB people of color.
Despite the strides made since the ACA was signed into law, there is room for improvement and expansion for the health care needs of TNB people. TNB people should be able to readily access quality and comprehensive care regardless of their gender identity and where they reside. It is important for providers to receive comprehensive training on how to best serve their TNB patients, for legislation to include protections for TNB people in the health care system and to continue to advocate for TNB people on the local, state and national levels.