Strides in Trans*-Related Health Insurance in the US
Editors Note: The author uses the term trans* as an inclusive terminology to refer to the diverse identities of trans* people within the gender identity spectrum.
Abstract
Recent strides of the trans*-rights movement have led to positive shifts in the tides governing the ability of trans* people to acquire necessary healthcare. These include the lifting of the United States Department of Health and Human Services’ generalized ban on trans*-related healthcare coverage for Medicare recipients, individual states banning insurance companies from blanket discrimination of trans* people, and the American Medical Association’s LGBT policies in support of trans* peoples’ healthcare. Despite these changes, trans* people face still discrimination in both healthcare and coverage. They are still one of the largest marginalized groups within the already stigmatized LGBT community, and having some of the highest rates of mental illness and suicide.
Gender variance first entered the medical sphere in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- III) as “Gender Identity Disorder”.1 There has since been a debate regarding its legitimacy and whether private insurance companies and government insurance policies should cover primary care for trans* people. In the fourth quarter of 2012, the controversial task force entrusted with producing the fifth edition of the DSM chose to change the naming of the diagnostic framework for transgender persons to “Gender Dysphoria”. Thus, the focus shifted towards gender incongruence as opposed to cross-gender identification.2 This was a major step in the long process of de-pathologizing gender variance.
On May 30th, 2014, the U.S. Department of Health and Human Services (HHS) removed its 33-year generalized ban on transgender related health services, such as hormone therapies and gender confirmation surgeries for Medicare recipients.3 The moratorium instated in 1981 declared that trans-related health services could lead to serious complications as they were considered to be experimental at the time.3 Following the ruling of the HHS Departmental Appeals Board, the American Civil Liberties Union, the Gay and Lesbian Advocates & Defenders, and the National Center for Lesbian Rights gave a supportive comment from the LGBT community:
“This decision removes a threshold barrier to coverage for medical care for transgender people under Medicare. It is consistent with the consensus of the medical and scientific community that access to gender transition-related care is medically necessary for many people with gender dysphoria. The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition-related surgeries denied. They should either get coverage or, at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment.4”
With the changes, these services are now considered medically necessary in the treatment of Gender Dysphoria by the American Medical Association (AMA), the American Psychological Association (APA), the American Psychiatric Association, and the World Professional Association for Transgender Health (WPATH). However, the fight for acceptance, equal opportunity, and comprehensive healthcare still ensues.
Some noteworthy strides in policy have also occurred in the years leading up to, and following, the HHS inclusion of trans*-related medical needs for Medicare recipients. The U.S. Equal Employment Opportunity Commission (EEOC) ruled that discrimination of persons due to being transgender is sex discrimination under Title VII of the Civil Rights Act of 1964 in the case of Macy v. Holder (2012).5 On June 30th, 2014, Tom Perez, secretary of the Labor Department, announced protections for its transgender employees which fall in line with federal nondiscrimination laws and the EEOC’s 2012 ruling.6 President Obama has also planned to sign an executive order forbidding companies in business with the federal government from discriminating against employees due to gender identity/expression and sexual orientation.7
The most striking development, though, was a bulletin issued by the District of Columbia’s Department of Insurance, Securities, and Banking on March 15th, 2013. This document prohibited gender identity-based discrimination by insurance companies under the District’s Unfair Insurance Trade Practices Act.8 In 2012, the Office of Civil Rights agreed “… that Section 1557’s sex discrimination prohibition [of the Affordable Care Act (ACA)] extends to claims of discrimination based on gender identity or failure to conform to stereotypical notions of masculinity or femininity and will accept such complaints for investigation.”9 Likewise, an announcement made by Mike Kreidler on June 25th, 2014, on behalf of the Washington State Insurance Commissioner stated that health insurance sold in Washington State cannot discriminate against transgender persons, citing both Section 1557 of the ACA and Washington State’s Law Against Discrimination (Chapter 49.60 RCW).10
In June 2008, the AMA added policy H-180.980 to their general policies regarding LGBT issues opposing the “… denial of health insurance based on sexual orientation/gender identity.”11 The AMA House of Delegates voted on June 9th, 2014, that proof of genital reconstruction surgery is not requisite for changing one’s gender designation on their birth certificate.12 It was argued that a birth certificate is rarely, if ever, used by practitioners when determining the appropriate course of treatment for an individual’s care, regardless of them being cis- or transgender.12 Further, it was stated that “… sex determination on an individual’s birth certificate must not hinder access to medically appropriate preventive care.”13 The AMA’s president, Dr. Ardi Dee Hoven, M.D., stated that the AMA “… seeks to ensure that transgender patients always receive appropriate preventive care regardless of whether or not it matches with the gender on the birth certificate.”13
These recent developments in both medical and political spheres shed a hopeful light on trans rights, health practices, and equal coverage for the near future. With the amount of media attention trans issues have been garnering as the next civil rights movement, one can only expect to see a stronger push for rights and equality. This move towards equal rights in policy will not come without significant push backs from opponents. However, even with policies in place for trans* peoples protection and equal treatment, another battle will continue, the battle for acceptance, normalization and de-pathologization in the social conscience.
References
1. Ford Z. (Dec. 3rd 2012). APA Revises Manual: Being Transgender Is No Longer A Mental Disorder. Retrieved from http://thinkprogress. org/lgbt/2012/12/03/1271431/apa-revises-manual-being-transgender-is-no-longer-a-mental-disorder/
2. Moran M. (April 5th 2013). New Gender Dysphoria Criteria Replace GID. Retrieved from http://psychnews.psychiatryonline.org/newsArti- cle.aspx?articleid=1676226
3. Heffernan D. (May 30th 2014). HHS: Medicare can no longer ban transgender healthcare coverage. Retrieved from http://www.glaad. org/blog/hhs-medicare-can-no-longer-ban-transgender-healthcare- coverage
4. American Civil Liberties Union. (May 30th 2014). ACLU Statement on Final Ruling Invalidating Medicare Ban on Healthcare for Trans- gender Patients. Retrieved from https://www.aclu.org/lgbt-rights/ac- lu-statement-final-ruling-invalidating-medicare-ban-healthcare-trans- gender-patients
5. McGovern AE. (June 21st 2012). Macy v. Holder: Title VII and Work- place Justice for Transgender Employees. Retrieved from http://www. jlpp.org/2012/06/21/macy-v-holder-title-vii-and-workplace-justice-for- transgender-employees/
6. Perez T. (June 30th 2014). Justice and Identity. Retrieved from http:// social.dol.gov/blog/justice-and-identity/
7. Parsons C, Memoli MA. (June 16th 2014). Obama to sign executive order curbing discrimination against gays. Retrieved from http://www. latimes.com/nation/la-na-obama-discrimination-20140617-story.htm- l#page=1
8. Department of Insurance, Securities, and Banking. (March 18th 2013). Department of Insurance, Securities and Banking and the Office of GLBT Affairs Announce Prohibition on Discrimination in Health Insurance on the Basis of Gender Identity or Expression. Re- trieved from http://disb.dc.gov/release/department-insurance-securities-and-banking-and-office-glbt-affairs-announce
9. Department Of Health & Human Services, Office For Civil Rights. (July 12th 2012). OCR Transaction Number: 12-000800. Retrieved from https://www.nachc.com/client//OCRLetterJuly2012.pdf
10. Kriedler M. (June 25th 2014). Letter to Health Insurance Carriers in Washington State Transgender health issues and discrimination. Retrieved from http://www.insurance.wa.gov/about-oic/news-media/ news-releases/2014/documents/gender-identity-discrimination-letter. pdf
11. American Medical Association. (n.d.). AMA Policies on LGBT Is- sues. Retrieved from http://www.ama-assn.org/ama/pub/about-ama/ our-people/member-groups-sections/glbt-advisory-committee/ ama-policy-regarding-sexual-orientation.page
12. Jaspen B. (June 9th, 2014). AMA Says Transgender Patients Don’t Need Surgery To Change Birth Certificate. Retrieved from http://www. forbes.com/sites/brucejapsen/2014/06/09/ama-says-transgender-pa- tients-dont-need-surgery-to-change-birth-certificate/
13. American Medical Association. (June 9th, 2014). AMA Calls for Mod- ernizing Birth Certificate Policies. Retrieved from http://www.ama-as- sn.org/ama/pub/news/news/2014/2014-06-09-modernizing-birth-cer- tificate-policies.page