The Stigma and Bias Making Health Insurance Terrible for Trans People

The Trump administration is threatening to roll back protections for transgender people guaranteeing them the same coverage as everyone else.

By Gillian Branstetter

Like millions of spouses around the country, Anton Prosser uses the insurance his husband receives from his employer.

“I’m a writer,” said Prosser. “You could say I’m a bit of a househusband.”

The 38-year-old from Austin, Texas was typically quite happy with his insurance coverage until he sought a prescription for hormone replacement therapy in 2014. Hormone replacement therapy is a commonly-prescribed treatment for transgender people like Prosser.

Prosser’s doctor refused to write the prescription because he “ knew absolutely nothing about transitioning,” said Prosser. Rather than look up basic information about the medications and widely accepted clinical guidelines, the doctor told him to find another doctor, giving him a list of thirty other doctors to “try.”

With no other choice, Prosser cold-called those other providers one by one. “I basically had to out myself every time on the phone and, oh my god, the responses that I got,” said Prosser. Most refused to see him, saying things like: “‘We don’t that crazy-ass thing here,’ ‘Don’t ever call here again,’ ‘We don’t do that in Austin, you’ll have to go to Houston.’”

“It was so upsetting and so horrible. I was so horrified,” said Prosser.

Hormone therapy is widely used to treat a variety of endocrine conditions, and is also a safe and reliable treatment for transgender people with gender dysphoria. Many doctors consider it part of primary care and don’t hesitate to prescribe it if recommended by a therapist.

Yet the only provider Prosser found who would was willing to write a prescription wasn’t on his insurance plan — forcing Prosser to pay out-of-pocket for the medications.

Many transgender people like Prosser are turned away by repeatedly by providers when trying to get basic care simply because they are transgender. Even when providers are willing to treat them, many insurance plans have completely exclude treatments for transgender people that are otherwise covered for cisgender people — from hormone prescriptions to mastectomies and hysterectomies.

Such discriminatory policies are illegal under the Affordable Care Act and many state laws. In 2016, the US Department of Health and Human Services published a rule for insurance companies to make this clear. This was a monumental step forward for transgender people; Out2Enroll studied over 800 Marketplace plans in 18 states and found over 95 percent of them had removed exclusions for transition-related care after the rule was published.

Now, the Trump administration is ready to pull away that rule for insurance companies (ignoring dozens of court rulings on the protections of Obamacare), abandoning transgender people who simply want coverage for the care they’re prescribed by their doctors.

Before the 2016 rule was published, these exclusions were one of the most common forms of medical discrimination faced by transgender people. According to the 2015 US Transgender Survey, one in four transgender people were denied insurance coverage for hormone replacement therapy.

The prescriptions themselves — which come in tablets, epidermal patches, or injections — are frequently inexpensive. But like any other medication, the costs of the mediations, lab tests, and doctor visits can pile up for any one patient.

This was the experience of Alyssa Ross, a 30-year-old transgender woman from Houston, Texas, when her employer forced her onto a new insurance plan. Her previous insurer had covered her HRT and the associated lab tests — her new one did not.

“Blue Cross Blue Shield of of Texas considered gender dysphoria an ‘uncovered diagnosis’ even though it was covered by our previous insurance policy, “ Ross told NCTE. Ross only discovered this change after seeing her doctor for a biannual check up and receiving a bill for $1,100.

“I am a healthy person, yet the one thing I need to use my insurance for isn’t covered.” said Ross. “I have to pay thousands of dollars now out of pocket simply because my insurance company doesn’t consider it a covered diagnosis and doesn’t offer any other explanation.”

Many of the costs and hardships faced by people like Ross and Prosser are dismissed by people who believe such treatments are cosmetic or somehow unnecessary. But basic care like HRT is endorsed by the American Medical Association, the American Psychological Association, the American Psychiatric Association, and a host of other medical communities.

These extra costs are also more likely to be a heavy burden for transgender people — who are typically less likely to be employed and more likely to live below the poverty line. Prosser notes his own luck in being able to cover the costs.

“I’m really lucky. I’m like the very last of the American middle class that I can afford these dumb bills,” said Prosser. “I’m very cognizant of the fact that I have the privilege to be able to afford these” when many other people like him can’t.

That leaves many transgender people effectively underinsured — meaning their insurance covers less than their doctors are prescribing them. According to a study by The Commonwealth Fund, more than one in four of all Americans are underinsured.

For many of those, insurance denials can amount to either an insurmountable barrier to receiving the care they need or a looming debt bringing them to the edge of bankruptcy. But for many transgender people like Alyssa Ross, it’s an outrageous way of life the Trump administration is set to make even worse.

“If cisgender women were treated like this and something routine like an OB/GYN visit wasn’t covered for some arbitrary reason, people would be outraged,” said Ross. “Yet, here I am.”

Denied insurance coverage because you are transgender? Treated rudely by a doctor or other health care provider? Visit our Know Your Rights page to stay informed.

To learn more about the Trump administration’s threat to the health of transgender people, visit ProtectTransHealth.org and learn what you can do to fight back.