Monthly Archives: April 2014

The Costs and Benefits of Eliminating Trans Health Care Exclusions

Transitioning to better health careMany public and private health care insurance programs have “transgender exclusions” that refuse to pay for transition-related care for transgender people.  One common argument against ending such exclusions is that covering the cost of transgender people’s surgeries and/or hormones would raise the cost of health care insurance premiums for everyone.

The State of California’s Department of Insurance found that not only was that a false assumption, but covering such care could even “lower costs.”

How is it possible that an expansion of health care availability could actually lower health care costs?  The answer lies in accounting for the costs of discrimination:  “The Department [of Insurance] has determined that the benefits of eliminating discrimination far exceed the insignificant costs associated with implementation of the proposed regulation [requiring insurance companies to cover transgender-related care]. …Further, the Department’s evidence suggests that benefits will accrue to insurance carriers and employers as costs decline for the treatment of complications arising from denial of coverage for treatments.” (p. 9)

First, let’s talk about the costs.  The Department looked at the costs incurred and projected to be incurred by several employers who decided to cover such care, including the University of California, the City of Berkeley, the City of Portland, the City of Seattle, and the City of San Francisco.  Projected cost estimates were much higher than actual costs turned out to be, in one case 15 times higher.  Once there was actual utilization data available, the various plans’ premiums increased, at most, by 0.19%.  In several cases, insurers determined no premium increase at all was needed to cover the transgender-specific healthcare. (pp. 6-7)

So how are actual savings possible?  The report addresses four specific ways in which overall health care costs for transgender “insureds” might decline:

1. A decrease in suicide attempts and completions.  Transgender people have an extremely high rate of suicide attempts, with one large national study showing that 41% of trans respondents had attempted suicide at least once.  The Centers for Disease Control and Prevention estimate the average acute medical costs of a single suicide attempt in the U.S. is $7,234.  This figure does not include post-attempt mental health care or ongoing medical costs.  The California Department of Insurance found multiple studies showing that the rate of suicide attempts by trans people drops dramatically among those who are able to access transition-related medical care.  The Department concluded, “These studies provide overwhelming evidence that removing discriminatory barriers to treatment results in significantly lower suicide rates.  These lower rates, taken together with the estimated costs of a suicide attempt and completion, demonstrate that the proposed regulation [banning trans-related health care discrimination] will not only save insurers from the costs associated with suicide, but prevent significant numbers of transgender insureds from losing their lives.”  (pp. 10-11)

2. The Department referenced multiple studies that found mental health improvements among transgender people who were able to access transition-related medical care, including decreases in the rates of depression and anxiety.  “This overall improvement in mental health and reduction in utilization of mental health services could be a source of cost savings for employers, insurers, and insureds,” the Department of Insurance concluded. (p. 11)

3.  Substance use and abuse is one of the ways in which transgender people try to cope when they cannot access transition-related medical care.  “There are numerous studies that provide evidence that substance abuse rates decline” when transgender people can access the care they need, the Department reported.  (p. 11)

4.  Transgender people – particularly transgender women – have much higher HIV rates than the general population (28% in a meta-analysis compared to a general population rate of 0.6%).  Studies have shown “high rates of adherence to HIV care for trans people when combined with hormonal treatment,” the Department said, which is “particularly relevant to insurers because it provides evidence that offering treatment may reduce the long-term costs of treatment for HIV/AIDS.”  Furthermore, this benefit extends to the general public:  “[w]hen compliant with care, HIV-positive people stay healthier longer and are far less likely to transmit the virus to others.”  (p. 11)

In addition to these ways in which health care costs might decline as a direct result of trans people being able to access transition-related care, the Department pointed out two additional types of benefits:

5.  One of the ways some transgender individuals cope with being denied surgical assistance in modifying their body so they feel safer or more comfortable is by using silicone injections.  These are often administered by laypeople without medical training, often using construction-grade rather than medical-grade silicone.  This practice is extremely dangerous and can result in many adverse health consequences and even death. (p. 12)

6.  Finally, the California Department of Insurance noted that multiple studies have found that transgender people have higher employment rates and improvements in socioeconomic status after they have had access to transition-related care. (p. 12)

You can access the whole California Department of Insurance report at http://transgenderlawcenter.org/wp-content/uploads/2013/04/Economic-Impact-Assessment-Gender-Nondiscrimination-In-Health-Insurance.pdf

The Shape of Housing Discrimination Against Same-Sex Elders

lgbt-senior-livingJust when some people suggest that discrimination against lesbian and gay people is a thing of the past, along comes a report that proves otherwise.

“Opening Doors: An Investigation of Barriers to Senior Housing for Same Sex Couples,” (available at http://www.equalrightscenter.org/site/DocServer/Senior_Housing_Report.pdf?docID=2361) is a 2014 report by The Equal Rights Center.  They conducted 200 tests across 10 states in order to see if same-sex couples seeking housing in independent living facilities (as well as some continuing care and assisted living facilities that include independent living units) were treated the same as opposite-sex couples seeking housing.

They found that in 60% of the calls they made between April and November 2013, the “family member” seeking housing for an older relative and their same-sex spouse received adverse, disparate treatment from the “family member” seeking housing for an older relative and their opposite-sex spouse.  Many times, it was the exact same rental agent giving the two callers different information.

How did the discrimination play out?

10% of the time, same-sex couples were told about fewer available units than opposite-sex couples.  This included telling same-sex couples there were no units available while opposite-sex couples were offered units, and offering only 2-bedroom units to same-sex couples requesting 1-bedroom units.

10% the rent quotes to the same-sex couple were at least $100 more than that quoted to the opposite-sex couple.  In six of those cases, the “heterosexual” prospective renter was offered a rental option that was $200 to $500 less.

21% of the time same-sex couples were asked for higher fees or deposits.

4.5% of the time the same-sex tester received significantly less information regarding available amenities than did the opposite-sex tester that spoke to that same agent.

5.5% of the time, the heterosexual tester was offered a special incentive to rent at the facility that was not offered the same-sex tester.

11% of the time, same-sex couples were told of additional application requirements — background checks, credit checks, proof of income, or a wait list — that were not discussed with heterosexual applicants.

It’s important to note, as the study report makes clear, “Housing discrimination does not just harm the targeted individual or couple, but hurts all of society.  Residents of senior housing facilities are denied the opportunity to live and learn in a diverse community; relatives and loved ones are more limited in the options available when assisted care is needed for their aging relatives; and non-seniors observe the stigma that may confront them in their retirement planning, dimming their prospects for a healthy, productive, optimistic retirement.”

Although the report makes various recommendations, it is interesting to note that whether or not the state explicitly outlawed housing discrimination against same-sex couples appeared to have little effect on how much disparate treatment couples in that state encountered:

State State prohibits LGB housing   discrimination % same-sex older couples treated less well % same-sex older couples treated less well in two or more ways
Arizona

No

80%

15%

Colorado

Yes

50%

10%

Florida

No

45%

10%

Georgia

No

70%

40%

Michigan

No

35%

5%

Missouri

No

45%

10%

New Jersey

Yes

40%

15%

Ohio

No

45%

5%

Pennsylvania

No

40%

10%

Washington

Yes

30%

5%

Overall

48%

12.5%

Trans Healthcare Exclusions — The History

trans healthcare oregonHow would you react if it turned out that your insurance company refused to pay for surgery your doctor said you needed based on an analysis of the surgery’s effectiveness published before the dawn of the internet?

Would you be concerned if you found out that federal equal opportunity educational policies were based on a position paper written by someone who believes African-Americans are an inferior race?

Would you want someone who had gone through a bitter divorce determining whether their ex-spouse should be provided life-sustaining medical treatment?

Would you agree that public policy ought to focus on the elimination of unwed pregnancies by refusing to pay for the health care of pregnant women who are unmarried?

If any or all of those scenarios appall you, you should be advocating for transgender health care justice, because all of these questions reflect the history behind trans people’s restricted access to health care services.

Currently five states and the District of Columbia have forbidden insurance companies from refusing to pay for care of transgender people; everywhere else such exclusions are not only legal, but ubiquitous.  Such “transgender exclusions” are typically said to exist because transgender related health care is “experimental,” “cosmetic,” “elective,” and/or “too expensive.”  In truth, all such treatments are routinely covered by insurance companies when they are provided to patients who are not transgender.  Furthermore, such exclusions were never based on medical evidence, but instead can be traced to one policy paper written by a person who had had unhappy experiences dating transsexual people and who had subsequently developed a rabid anti-transgender philosophy.

You cannot find an online, original copy of “Technology on the Social and Ethical Aspects of Transsexual Surgery,” by Janice G. Raymond because it was written in 1980, before the World Wide Web existed.  Transcribed copies can be found in a variety of places, including http://auntyorthodox.tumblr.com/post/82585002623/technology-on-the-social-and-ethical-aspects

The paper was written at the request of the National Center for Health Care Technology (NCHCT), which was a government-funded body that was charged with making evidence-based judgments about the efficacy of medical technologies.  Rather than consulting medical experts, NCHCT asked Janice Raymond, an assistant professor of medical ethics and women’s studies at the University of Massachusetts, to address the issue of the medical care of transgender people.  The year before, Raymond had published The Transsexual Empire: The Making of the She-Male, arguing that not only was it impossible to change one’s sex, but that those who did so were anti-feminist.

The NCHCT paper was filled with political and even inflammatory statements.  Raymond said medical care of transgender people brought up “questions of bodily mutilation and integrity,” argued that “transsexualism is an ethical” issue, and called for “the elimination of transsexualism.”  She worried that clinics that specialized in working with transgender people “could become potential centers of sex-role control for non-transsexuals – e.g., children whose parents have strong ideas about the kind of masculine or feminine children they want their offspring to be.”  She made an analogy between medical care of transgender people and “oppressed people us[ing] heroin to make life tolerable in intolerable conditions.”  Just as the “contentment and euphoria produced by the drug [heroin] diffuses the critical consciousness of the user,” she said, “Transsexual surgery produces satisfaction and relief for the transsexual at the expense of muting his or her critical consciousness of the ways in which such surgery reinforces sex role behavior.”

When she did address legitimate medical issues, Raymond did so in a skewed and misleading way.  For example, she stated that “[t]ranssexual treatment…has been known to cause cancer,” citing two cases of breast cancer in trans women.  She suggested “that the malignance was entirely due to the hormonal imbalance created by castration plus the massive doses of estrogen received.”  Apparently she felt the fact that breast cancer is extremely common in women across the board, whether or not they have ever taken estrogen pills, had no relevance.

Despite the obvious political bias of its author, “Technology on the Social and Ethical Aspects of Transsexual Surgery” became the basis of Medicare’s exclusion of coverage for transgender related care.  Medicare’s decision, in turn, led to the exclusion of such care not only in other public programs such as Medicaid, but also by most health care insurance companies.

And that is how one woman’s personal 1980 prejudices and worldview came to shape medical care for thousands and thousands of transgender people ever since.

Trans People, Marriage, and Social Security

social security cardAfter sustained lobbying by the National Center for Transgender Equality and others and after Robina Asti’s public statement (see http://www.grayprideparade.com/2014/01/29/i-was-shocked-i-was-shamed/), the Social Security Administration has finally issued guidance telling staff to automatically assume that most marriages involving transgender people are valid.

Of course, given the mish-mash we currently have with some states refusing to recognize other states’ “same-sex” marriages and some states’ bad decisions concerning the legal gender of transgender people, the guidance is complicated.  The guidance now requires Social Security staff to determine where the marriage was performed and if the sex change took place before or after the marriage.  If the sex change took place before the marriage and the transgender person currently lives in (or died in) American Samoa, Florida, Idaho, Kansas, Ohio, Oklahoma, Puerto Rico, Tennessee, Texas, or the Virgin Islands, a legal opinion about the validity of the marriage is still required.  Otherwise, marriages involving transgender people are to be treated under existing rules for opposite-sex and same-sex marriages, bypassing the current procedure of referring all marriages involving transgender people to legal counsel.

The actual bureaucratic memo is available at https://secure.ssa.gov/apps10/public/reference.nsf/links/03252014040307PM  (Trigger warning: in discussing sample cases, the memo uses typical bureaucratizee about applicants “alleging” personal facts.)