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OutServe Magazine | March 4, 2013

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Me, the ACA and Transgender Coverage

Me, the ACA and Transgender Coverage

by Brynn Tannehill

As I transitioned, health care coverage has truly been a trip through the looking glass. When I started the process, I worked for a company which had health benefits that extended to same sex partners.  It also covered many transition related expenses such as labs for hormone levels, Gender Identity Disorder (GID) related doctor and therapist visits, surgeries related to a sex change, and hormone therapy.

However, my luck ran out at about the same time I fully transitioned.  The next company I went to did not offer any benefits to same sex partners.  It will not cover any GID related medical coverage.  This has led to some very odd work-arounds to ensure my family has benefits.  My driver’s license, passport, DEERS information, CAC card, and company records say I am female.  All of my wife’s documentation says she is female.  However, I had to prove my marriage is NOT same-sex by providing a joint 1040 form and my Florida marriage license to the benefits department. At my doctor’s office, they are re-coding my records as female so they can use non-GID related codes for my appointments, labs, and prescriptions for hormones.

In other words, I have to be legally both male and female at any given time, depending on who is looking at that moment.

The transgender community has suffered disproportionately from several issues including unemployment, under employment, lower pay when equally qualified, higher HIV infection rates, lack of access to health insurance, and discrimination by health care providers.  The landmark study by National Center for Transgender Equality (NCTE) surveyed a remarkable 6,000+ transgender individuals to assess the state of transgender people in the US, and devotes a chapter to health care issues.

President Obama’s landmark Affordable Care Act (ACA) addresses all of these issues.  The NCTE has put together an excellent briefing describing the benefits of the ACA for transgender individuals.

The downside is that state provided health care pools are unlikely to cover most or all of the expenses usually associated with transition.  This includes counseling or therapy for Gender Identity Disorder (GID), Hormone Replacement Therapy (HRT), lab tests as a part of HRT, Facial Feminization Surgery (FFS), of Sex Reassignment Surgery (SRS).  It might seem counterintuitive to discover insurance policy writers cannot discriminate against transgender people, yet don’t provide any services directly related to being trans; the language of the ACA only applies to the issuance of policies, not what they cover.  In other words, it is not discriminatory if no one has Gender Identity Disorder (GID) related issues covered.
According the annual Human Rights Campaign (HRC) Corporate Equality Index (CEI) survey, an increasing number of corporate health policies have been covering some or sometimes even all of these treatments.  This type of coverage tends to be with higher-end, comprehensive policies. While neither side in the debate over health care agrees how many of these higher-end policies will be dropped, there is agreement that some companies will.  The Congressional Budget Office assessed how many companies were expected to drop coverage as part of their estimates of the costs associated with the ACA.

Without the ability to produce my own hormones anymore I am susceptible to a host of medical issues if I do not have access to HRT and lab work.  For others who need psychological support, access to care can be a matter of life and death.  If I had not had access to a therapist with experience in gender dysphorias, I doubt the outcome of my transition would have been this smooth.  The recent National Center for Transgender Equality survey found that 41% of transgender people have attempted suicide.  An unknown number succeed.  Based on both these criteria, coverage for GID related issues is a legitimate need.

The practical upshot is that getting basic health care will be easier, but policies covering transition related issues will likely become less common in the near future. For those already in the private sector, some of this risk can be mitigated by how your doctor or therapist codes their treatments and prescriptions for insurance purposes. Some doctors may agree to this, other may not wish to take the chance. For current service members the best way to ensure you have ongoing access to GID related care is to make sure references to your GID issues are already in your medical records before you leave.

Since June 2011 it has been official policy that the Veteran’s Administration can provide mental health counseling, hormones, and pre and post-operative care to transgender veterans. Genital surgery is still forbidden. Obtaining these non-surgical treatments after leaving the military may be easier when it has already been noted in your medical records as a pre-existing condition.

VA health benefits are available to many people even if they did not serve 20 years or suffer a service related disability.  Anyone who has served in a combat theater in the past five years is likely to be eligible.  Eligibility is determined when an application is submitted.

The transgender community will disproportionately benefit from the ACA due to existing discrimination in employment and health care, as well as a general lack of legal protections.  However, the ACA leaves out guarantees of coverage for GID related issues.  The ACA is treating the symptoms of GID, but not the cause.  Failure to address  the underlying issue has a demonstrably high mortality rate.  I am lucky; I have been able to keep my benefits through some legal loopholes without VA assistance.  Most other trans people are not so lucky.  This gap in coverage needs to be fixed.