This post is updated since its original publication on November 8, 2018.
This week the Supreme Court ruled that LGBT people are protected from employment discrimination. This decision comes just a week after the Trump administration finalized a rewrite of Section 1557 of the Affordable Care Act. Section 1557, which prohibits discrimination based on race, color, national origin, sex, age, or disability, was defined in 2016 as applying to gender identity. As a result of that 2016 definition, health providers and insurance companies that received federal funding had to provide the same access to coverage, services, and care to transgender people that they would to cisgender people (i.e., those whose gender identify matches the sex they were assigned at birth).
The new rule effectively eliminates these protections. As a result, trans people may now face discrimination in accessing health services, receiving care consistent with their gender identity, and getting coverage for gender transition services. In the final rule, the U.S. Department of Health and Human Service Office of Civil Rights states that it expects half of 137,501 covered entities — including hospitals, insurers, state Medicaid agencies, community health centers, and physician practices — to rescind these protections through changes in policies and procedures.
The new rule comes during the COVID-19 pandemic, a time when increasing access to care for all patients is critical. This could have devastating implications for the health and health care of transgender and gender-nonconforming individuals during the pandemic and in the long term, placing an already vulnerable population at greater risk.
One of the Most At-Risk Populations
The approximately 1.7 million trans people in the United States face significant hardships that increase their risk of poor health outcomes. First, two of five (39%) report having low incomes (i.e., earning less than $30,000 a year per household), which can have negative effects on health. In addition, trans people are more likely than the general population to face discrimination in education and employment, abuse by the police, harassment in public spaces, and physical, verbal, and sexual assault. Nearly all of these issues are worse for trans people of color.
The toxic stress of living as a trans person in America can negatively affect physical and mental well-being. Trans people are more likely than their cisgender counterparts to report poor physical health, experience mental health issues like anxiety and depression, and have substance abuse problems. Forty percent have attempted suicide, compared with 4.6 percent of the general population.
Poor Access to Quality Health Care
Transgender people often face barriers to getting the health care they need. One of five transgender adults is uninsured. Trans people often skip health care because of cost: nearly half (48%) have postponed medical care when sick or injured and avoided preventive care (50%) because they couldn’t afford it.
Trans people often hide their gender identities from health providers out of fear of retaliation and harassment. Only 40 percent of trans people report being out to all their medical providers. It’s understandable that many would want to conceal this information: 28 percent of trans people report experiencing verbal harassment in a medical setting and 19 percent report having been refused medical care by providers because of their gender identity. Because of stigmatization and harassment, 28 percent of trans people report avoiding care altogether.
Of those who do make it to the doctor and disclose their gender identity, half report having to teach their medical providers about transgender individuals’ health care needs and appropriate medical care. Lack of awareness on the part of medical providers — in part because of lack of training — has serious implications for care quality. Moreover, when people veil their identities in medical settings, their providers miss important information that should inform screening, diagnosis, and care.
The Consequences of Erasing Transgender Rights
For trans people, health care visits can add to distress, rather than provide help. The American Medical Association (AMA) opposes policies like the final rule that could harm trans people, stating that “laws and policies that restrict the use of public facilities based on biological gender can have immediate and lingering physical consequences, as well as severe mental health repercussions.” The AMA recommends equal access to care that corresponds with a person’s gender identity “to protect the public health and to promote social equality and safe access to public facilities and services.”
Now that the protections of Section 1557 no longer apply to trans people, they may face greater discrimination, leading to more avoidance of care and, ultimately, more unmet medical and behavioral health needs.
The announcement of the rule comes during the COVID-19 crisis when access to care is critical. In the long term, however, the rule will face legal challenges that will be difficult for the administration to defend. The Supreme Court ruled this week that Title VII of the Civil Rights Act of 1964, which prohibits employment discrimination, also applies to LGBT individuals.