How Medicare for All Could Improve—and Save—the Lives of Transgender People

Arya Serenity started using GoFundMe in 2018, just before being released from prison. With the help of people on the outside, she ran two campaigns to raise a few thousand dollars to defray the cost of housing, re-entry, and buying women’s clothing and cosmetics for the first time. A year later, she returned to the platform again to pay for facial hair removal.

Arya is a transgender woman, someone who was assigned male at birth and identifies as a woman. She’s also part of a growing cohort of gender diverse individuals who are turning to online platforms like GoFundMe to ask their communities for direct assistance in covering the costs of their transitions. A quick search for ​“top surgery” on the website will turn up over 27,000 results, and ​“bottom surgery” yields some 16,000 more. There are also thousands more campaigns from people asking for aid to cover the cost of hormones, gender confirmation surgeries, laser hair removal, and other expenses related to medical transition.

These services can quickly add up to tens of thousands of dollars. Arya scoffs at the thought of being able to afford the full scope of gender affirming care that she would like: ​“Hell no. I can barely pay my rent.”

But with Medicare for All maintaining broad popular support and its chief political proponent — Sen. Bernie Sanders (I-Vt.)—surging to the lead in the Democratic primary, that calculation may soon change. 

The proposed policy would be a major intervention in a system where over 1.3 million Americans who identify as transgender or gender diverse are systematically shut out of health care coverage. Currently, only 19 states and the District of Columbia require government insurance to cover gender affirming care, and nine states explicitly exclude it. The gender diverse community is uninsured at more than double the percentage of the general population. And in a system where health insurance is tied to employment, gender diverse people are three times more likely to be unemployed than cisgender people, whose gender matches the sex they were assigned at birth. According to the National Center for Trangender Equality, ​“More than one in four transgender people have lost a job due to bias, and more than three-fourths have experienced workplace discrimination.” This reality is even worse for transgender people of color, with nearly half of Black transgender Americans reporting harassment at work.

With Medicare for All, these coverage disparities could instantly disappear. 

Sen. Sanders, who introduced the Medicare for All bill in Congress in 2019, describes the program as a ​“single-payer, national health insurance program to provide everyone in America with comprehensive health care coverage, free at the point of service.” The Sanders campaign told In These Times over email that Medicare for All ​“would not only confront the massive health disparities faced by the LGBTQ+ community, it would also cover gender affirming surgeries, increase access to PrEP, remove barriers to mental health care and bolster suicide prevention efforts. Sanders’ plan clearly states that LGBTQ+ people cannot be discriminated against by providers or denied health benefits.”

For her part, Elizabeth Warren, the only other presidential hopeful to make Medicare for All part of their official platform, has also promised to expand health care access for sexual and gender minorities. Her website states that a Warren administration would ensure coverage for ​“all medically necessary care for LGBTQ+ patients under Medicare for All, and [allow] providers discretion to deem gender-affirming procedures as medically necessary based on an individualized assessment.” Some, however, have questioned whether she actually plans to make Medicare for All a legislative priority, given that her timeline for achieving it stretches deep into the second half of her hypothetical term.

Daniel Merrill is a transgender woman and co-chair of the Cincinnati and Northern Kentucky chapter of the Democratic Socialists of America. She says that a strong Medicare for All program would be life-saving, noting that access to gender-affirming care ​“significantly lowers the suicide rate among transgender people and significantly reduces the rate at which they are violently accosted by people in public.” With life expectancy for transgender women of color currently as low as 35 due to high rates of racist and transphobic violence, Merrill’s comments reveal another layer of health disparities faced by transgender and gender nonconforming populations, one that Medicare for All could help alleviate.

Under the current system, privately insured Americans seeking gender affirming care can easily fall through the cracks. Coverage varies widely between policies, and in some cases, insurance carriers will simply deny coverage for procedures that are ostensibly covered in their policies. Arya Serenity says she discovered this when she tried to get facial feminization surgery (FFS) last year. After leaving prison, she says she found work at a support center for transgender people. Through that position, Serenity says she has been covered with Blue Cross Blue Shield’s Platinum PPO plan, which she says she specifically chose because it covers FFS. Despite this, Serenity’s insurance has repeatedly denied her FFS requests, she says. (The company did not immediately reply to a request for comment.)

“They consider it cosmetic,” she says. ​“For them to be able to determine that for someone else is beyond me.” She added, ​“It’s so angering.” 

She says she once tried to get authorization from a specialist, but he told her not to bother, because insurance wouldn’t cover it. Besides, the specialist said, she looked feminine enough already. The whole visit lasted less than 15 minutes and left Serenity thinking to herself, ​“Wow, this is what I signed up for?”

With current iterations of Medicaid, gender diverse people also can struggle to access care. This was the case for Theo Strachan, a transgender man who is insured through Medicaid in Maryland. Strachan says he was forced to pay out of pocket for a visit to the OB/GYN because Medicaid flagged the request for gynecological care for a man as fraudulent. Strachan says that when he called the Maryland Department of Health to clear things up, ​“it got very invasive very quickly.” According to Strachan, the department official with whom he spoke asked about his anatomy and began talking to him about god. He says the entire experience was ​“humiliating.” A representative of the Maryland Department of Health told In These Times via email that the Department was not able to comment on matters involving personal health information.

It could get even worse. Last summer, the Trump administration proposed a dramatic revision of Section 1557 of the Affordable Care Act that would eliminate nondiscrimination protections based on gender identity, sex, and association in programs that receive federal funding. While it is not entirely clear what such changes would entail, many are concerned that, if implemented, the rollback could lead to an increase in discrimination against transgender and gender divrese people.

For Dr. Alex Keuroghlian, who is the principal investigator of the federally funded National LGBT Health Education Center and the director of the Massachusetts General Hospital’s Psychiatry Gender Identity Program, anecdotes of denial of care are a big concern. ​“We have national data indicating that adverse experiences within the health care system — being misgendered or invalidated or denied treatments related to your gender identity — is a reason many transgender and gender diverse people cite for not engaging in needed urgent or preventative medical care.” Keuroghlian says this dynamic leads directly to health inequities down the line. 

As for insurance difficulties, Keuroghlian says, ​“We hear it all the time. It ends up being a lot of extra work at health centers or in care teams for clinicians to process appeals and engage in additional advocacy — and a lot of extra work and emotional labor for the patients.” 

Under Sanders’ Medicare for All proposal, such discrimination would be explicitly banned, and courts would be able to award damages if this ban was violated. Warren says she will ​“immediately work to repeal the Trump Administration’s terrible proposed rule permitting discrimination against LGBTQ+ people in health care.”

According to Jessica Halem, LGBTQ outreach and engagement director at Harvard Medical School, Medicare for All creates another important opportunity to improve access to gender affirming care: It would release providers from having to fight with insurance companies over patient care and reduce time spent on administrative work by streamlining paperwork and electronic records. As Halem puts it, ​“Medicare for All is an opportunity to free up doctors to do what they do best.”

Furthermore, says Halem, having a federal policy that validates best practices for gender affirming care would create a ​“trickle down effect” that would lead to greater acceptance for gender diversity throughout society. ​“Because you’ve got this beloved expert in our culture,” says Halem. ​“We put [doctors] on this pedestal.” Halem says that when doctors affirm gender diversity, ​“then everyone else falls in line.”

Keuroghlian says that training is key to ensuring access to gender affirming care. ​“The thing is clinicians aren’t trained to provide this care,” he says. ​“We need to reform medical education, nursing education, social work education. You can have the coverage, but if you don’t have enough care teams who know how to deliver this care, it’s not going to get delivered.” 

Some argue that the medical system requires deep cultural intervention, as well as structural change. Danny Waxwing, attorney and director of the Trans in Prison Justice Project at Disability Rights Washington, says ​“a lot of issues come about because we’re still using the framework of medical necessity in a conversation that is fundamentally about self-determination.” As Arya Serenity experienced when she was denied FFS on the grounds that it was cosmetic, what constitutes ​“medical necessity” is not ultimately up to the transgender or gender diverse person who is seeking care. To meet the needs of gender diverse people, advocates say a Medicare for All system would have to ensure that individuals have agency and voice in determining the care they need. 

Daniel Merrill, a supporter of Medicare for All, says of the proposed program, ​“I’d like to see more protections for adolescents in gaining access to puberty blocking treatments, particularly autonomy in making choices regarding their gender identity from their parents.” Neither Warren nor Sanders directly addresses this point in their plans, despite the fact that more than a dozen states across the country are advancing bills that target transgender youth, either by banning certain kinds of gender-related medical care or barring them from playing on school sports teams associated with their gender identities. On January 30, South Dakota’s House of Representatives approved a bill that would make it a misdemeanor for doctors to provide gender affirming care like puberty blockers to patients under the age of 16 years old. While only a minority of gender diverse youth currently receive this treatment, a recent study found that the therapy can have significant benefits for the mental health of those who do. 

Of course, if one cannot afford to go to the doctor to seek care in the first place, none of this matters. Theo Strachan, pointing to Medicare for All’s ability to make health care accessible for transgender people of color who are living in poverty, says, ​“I’m for it.”

Arya Serenity says she’s cynical that Medicare for All would deliver, asking, ​“Who’s going to pay for that?” She’s determined to move forward with her transition, and to do her best to get the care she needs. When she walks down the street, she says, she wants people to think ​“Damn, she’s cute. Or damn, she’s ugly, but at least it’s a ​‘she.’” That, she says, would ​“change everything.”

Merrill, on the other hand, emphasizes that the relief that Medicare for All would bring cannot be overstated. She says there’s a person she wants to be, but for a long time she assumed she would never be able to afford it. With Medicare for All on the table, she underscores, ​“It’s the first time I’ve believed that it’s possible.”