Tag Archives: Health care

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

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.

An Ally’s Guide to LGBT Issues

Ally's GuideTomorrow the U.S. Senate Committee on Health, Education, Labor and Pensions is scheduled to take up — and expected to send on to the full Senate — the Employment Non-Discrimination Act (ENDA), a long-pending bill that would outlaw employment discrimination against LGBT people.

In honor of this new ENDA push, we dusted off our copy of “An Ally’s Guide to Issues Facing LGBT Americans,” a guide that was collaboratively produced by a number of LGBT organizations.  It addresses what some would call “The Gay Agenda,” giving data and background on the following LGBT wish list: Continue reading

LGBT Cancer Survivors

rainbow ribbon“Cancer doesn’t discriminate, but the healthcare system often does….”

So starts the conclusion of a new report, “LGBT Patient-Centered Outcomes:
Cancer Survivors Teach Us How to Improve Care for All,” issued by the National LGBT Cancer Network and the Network for LGBT Health Equity. Continue reading

Health Care Professionals for LGBT Rights

GLMAGot a supervisor, elected official, or other authority figure you want to persuade to adopt more LGBT-friendly policies?  The Gay and Lesbian Medical Association (GLMA) has compiled a tool that you may find helpful.

Their newly-updated “Compendium of Health Profession Association LGBT Policy & Position Statements” compiles information on and links to LGBT-related policy statements made by 11 different health care professionals’ groups ranging from the American Academy of Family Physicians to the American Public Health Association (apparently no health care professional association is going to start its acronym with anything other than “A”).  

Continue reading

Hospital Hires Director of LGBT Health Services

A short article on Barbara Warren, Beth Israel Hospital’s Director of LGBT Health Services, discusses some of the issues she is facing in implementing LGBT cultural competency training and including sexual orientation and gender identity in electronic medical records.  The article also notes that she has gotten a small grant to do a wellness series called “Ask the Docs” at SAGE’s senior center, the LGBT Center, and Gay Men’s Health Crisis.  You can find the article at http://nypress.com/longtime-lgbt-advocate-pioneers-new-health-services/

American Psychiatric Association Issues Transgender Statement

The place of transgender and gender variant people in American society is rapidly changing.  Another marker of this change was issued this summer by the American Psychiatric Association (APA).  The APA formed a task force on the treatment of gender identity disorder (GID) – the psychiatric label the APA assigned to transgender people in 1980 – to “perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA.” Continue reading

HHS LGBT 2012 Report Available

Wondering what the federal government has done for the LGBT community lately?  A good place to start getting answers is an 11-page-long report that the U.S. Department of Health and Human Services (HHS) published last month, available at http://www.hhs.gov/secretary/about/lgbthealth_objectives_2012.html

The report goes over nine 2012 objectives.  Those most relevant to LGBT aging issues include:

  • Releasing a report that “identifies the gaps and oppportunities in its portfolio in light of the recommendations that the Institute of Medicine made in its 2011 report entitled, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.
  • Funding five pilot studies to reduce obesity in lesbian and bisexual women.
  • With the Centers for Disease Control and Prevention, assessing the impact of new chronic disease prevention programs on LGBT populations;
  • Conducting a comprehensive review of LGBT cultural competency training curricula and improving training for programs delivering integrated health services to LGBT clients; and
  • Through a partnership between the Centers for Medicare and Medicaid Services and the Administration for Community Living, “release a training video to educate long-term care ombudsmen, surveyors, healthcare providers, and state and local government officials about LGBT older Americans, the impacts of the social stigma on this community, and the rights of consumers in nursing homes, hospice, and health care.  The video will highlight best practices, identify resources to support LGBT older adults, and give instruction on what to do if one becomes aware of discrimination based on sexual orientation or gender identity.  In addition, CMS will clarify its rules governing nursing home visitation rights, which are already in place and apply equally to those with same-sex domestic partners.”

The report also notes that the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Administration on Aging has issued five grants focused on improving behavioral health services and on suicide prevention among older people.  Two of theswe grants — to the Jewish Family Service of Los Angeles and the Montrose Counseling Center in Houston — specifically target LGBT seniors.

LGBT-Friendly Cancer Screening Facilities

The National LGBT Cancer Network recently announced a major expansion of its directory of LGBT-friendly cancer screening facilities, including offering a starred designation for facilities that have trained all staff on transgender issues and reached out to their local transgender community.

“LGBT people are at increased risk of cancer, not due to any physiological differences, but behaviors, many of which result from the stress of living as sexual and gender minorities in this country,” Liz Margolies, Executive Director of the National LGBT Cancer Network, explained.  She noted, for instance, that “Gay men have very high rates of HPV, the virus that can lead to anal cancer.  In fact, anal cancer rates in this population are 40 times higher than in the general population.  A simple screening procedure, an anal pap smear, can test for precancerous changes, but too few men are aware of the need for or existence of the test, or out to their provider who could then recommend it.”

In addition to their searchable directory, the National LGBT Cancer Network also offers an automated Electronic Prompt that can help you keep track of when you are due for another screening, and a risk assessment tool to help you pinpoint where you may be at increased risk of various types of cancer.   The directory, electronic prompt, and risk assessment tool are all available through the Natinoal LGBT Cancer Network’s homepage, at http://www.cancer-network.org/  An article on the expansion of the directory is available at http://miamiherald.typepad.com/gaysouthflorida/2012/04/national-lgbt-cancer-network-adds-300-facilities-and-transgender-friendly-designation.html

Medicaid, Obamacare, and LGBT People

Last week’s Supreme Court decision upholding the constitutionality of most of the provisions of the Affordable Health Care Act (popularly known as “Obamacare”) left in place upcoming changes to Medicaid that will particularly help low-income LGBT people.

The new law permits states to expand Medicaid coverage to all Americans under the age of 65 who make less than $15,000 per year (the Supreme Court struck down the provision that would have withheld ALL Medicaid funds from states that refused to do so, making this now a truly optional program).  This provision could provide care to an additional 16 million currently uninsured people, including many LGBT people, who on average have less income than non-LGBT people.  The provision also extends Medicaid coverage to people living with HIV earlier in the course of the disease, again affecting a disproportionate number of LGBT people.

A blog post on this topic, written by two health policy analysts for LGBT Progress, is available at http://thinkprogress.org/lgbt/2012/06/28/508590/how-medicaid-expansion-affects-gay-and-transgender-communities/