Over the past few years, there has been a heartening and historic trend toward expanding insurance access for transgender people, including coverage for transition-related care of the kind Bruce Jenner spoke about during an interview with Friday with ABC interview with Diane Sawyer.
But this great progress obscures a troubling medical reality: the increase in coverage of and demand for transition-related services has not been met with an increase in the competency of most medical providers, an increase in inclusive services or an increase in access to care.
Let’s look at the good news first.
At the HRC Foundation, our annual benchmarking reports that not only measure, but also advance, LGBT-inclusive policy and practices, have tracked years of progress in transgender healthcare:
- More than a third of Fortune 500 companies now offer transgender-inclusive health benefits, driven in large part by LGBT workplace quality benchmarks set by HRC’s Corporate Equality Index (CEI).
- Nine states and the District of Columbia prohibit health insurers from offering plans that exclude transgender healthcare, and five states and DC offer transgender-inclusive health plans to public employees, according to HRC’s State Equality Index (SEI), which reviews statewide laws and policies that affect LGBT people and their families.
- According to HRC’s 2014 Municipal Equality Index, 42 of 353, or 12%, of the cities assessed on their LGBT-inclusive policies and practices provided transgender-inclusive health benefits to public employees.
- And, in line with standards established by the non-profit Joint Commission that accredits hospitals, HRC’s 2014 Health Equality Index shows that 97% of hospitals responding to the benchmarking survey had fully inclusive patient non-discrimination policies that include sexual orientation and gender identity.
This progress has been mirrored at the federal level, where last year a federal panel ruled that Medicare can no longer categorically exclude coverage of transition -related healthcare. Several federal employee health benefit providers now offer coverage this care, and, perhaps most significantly, under the Patient Protection and Affordable Care Act (ACA), more transgender people are gaining insurance coverage and protection through the Exchanges and Medicaid. Although we are still awaiting formal regulations from HHS, the Office of Civil Rights has clarified that Section 1557 of the ACA prohibits discrimination against transgender people in health programs that receive federal funding, including insurance coverage.
Now for the flip side: a dearth of providers and systems to provide adequate coverage. Consider the following:
- General healthcare practitioners frequently lack cultural competency and clinical knowledge about transgender health issues. Most medical schools do not provide sufficient cultural competency training pertaining to transgender people.
- There are very few providers of transition-related surgery; most geographic areas have none. And even where providers exist, they are not accustomed to taking insurance for transgender-related services and typically have no systems in place to do so.
- Even when coverage exists, provider reimbursement is frequently inadequate and transgender people face daunting obstacles before insurance will actually pay for care.
- There is no accreditation of training for transgender-related medical services, nor is there certification of expertise in transgender medicine. Although the World Professional Association for Transgender Health (WPATH) provides Standards of Care for transgender healthcare, this guidance is non-binding for providers and insurers.
There have been modest signs of progress. New guidelines to improve the healthcare provided to LGBT people have been published by the Association of American Medical Colleges. In the District of Columbia, HRC is supporting legislation that would require that healthcare providers receive such training on an ongoing basis.
But without sufficient standardization, and as demand for transgender-related medical services grows, transgender people are increasingly at risk of receiving inappropriate or negligent care that can result in physical and psychological suffering.
Insurance providers, hospitals, and physicians must take a serious look at how to professionalize their care of transgender clients and patients, and how to ensure that needed medical services are available. Because of a legacy of excluding transgender people from healthcare, it will take several years to fully integrate transgender-related healthcare into our health systems. But make no mistake, this complex and often frustrating work is necessary to ensure that transgender people have access to medically necessary care that is competent, sensitive, and free from discrimination.