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

Transgender people are systematically shut out of medical coverage. Medicare for All could change that.

Izii Carter

On July 26, 2017, thousands of New Yorkers took the streets of in opposition to protest President Trump's anti-transgender policies. (Photo by Michael Nigro/Pacific Press/LightRocket via Getty Images)

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.

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

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.”

Izii Carter is an edi­to­r­i­al intern at In These Times.
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