Why Trumpcare Puts Trans Health on Life Support

Trans people often face denials of coverage despite having health insurance—and the American Health Care Act makes their situation, as well as the uninsured, even more precarious.

For all that you’ve heard about bathrooms over the past year, it is health insurance that may be the most pressing issue facing transgender people under President Trump.

The American Health Care Act, which narrowly passed the House last week, would cause millions of people to lose their health insurance if it passes the Senate in its current form. The nonpartisan Congressional Budget Office estimated that a previous version of the bill, which did not pass, would increase the uninsured count by 24 million people. At the time of the House vote, the CBO had not yet estimated the impact of the revised legislation but it certainly won’t reduce the uninsured rate.

And that’s especially bad news for 1.4 million transgender Americans who are not only more likely to be uninsured than the general population, but who frequently face denials of coverage even when they do have health insurance.

Fourteen percent of respondents to the 2015 U.S. Transgender Survey were uninsured, which is slightly more than the 11 percent of the general population who do not have health insurance. When broken down by race, however, that data—collected from over 25,000 respondents by the National Center for Transgender Equality—reveals even more striking disparities: A full 20 percent of black transgender respondents said they did not have health insurance and 17 percent of Latino respondents said the same.

Transgender people who do have health insurance still face substantial problems: One in four who tried to get coverage for hormone therapy said they were denied—and over half of those who sought surgical coverage were also turned down. All this despite the fact that hormone therapy and transition-related surgery have been described and supported as medically necessary treatments by several major medical associations.

The troubles don’t stop there, either: 13 percent said they were denied coverage for services like Pap smears and mammograms, and seven percent said they were even turned down for other forms of “routine health care,” like physicals. And getting into the doctor’s office is no guarantee of good treatment: A third of respondents reported having “at least one negative experience with a doctor or other health care provider related to being transgender” in the last year.

All of these problems could get worse. Some of them have already been taking a turn.

In all of the drama surrounding the Trump administration’s stance on LGBT rights, the Obama administration’s stance on transgender health care has been unraveling in the background.

Trump himself has yet to sign a major anti-LGBT executive order, despite two periods of intense speculation to that effect. The administration did, however, rescind Obama-era guidance from May 2016 instructing school districts to allow transgender students to use restrooms matching their gender.

But the Obama administration delivered another crucial but precarious victory for transgender people last May that has received much less attention than the bathroom guidance: A Department of Health and Human Services rule stating that Section 1557 of the Affordable Care Act, which bans sex discrimination, effectively bars health care providers from denying transition-related medical care like hormones and surgeries.

A federal judge in Texas issued a preliminary injunction against that HHS rule on Jan. 31, 2016—a decision that paved the way for the University of Arkansas system and the state of Wisconsin to retract transition-related medical care from employee health insurance plans without fear of federal enforcement.

And last week—while we watched and waited to see whether or not Trump’s “religious liberty” executive order would allow for sweeping anti-LGBT discrimination—the administration quietly signaled the death of that HHS rule. As Rewire’s Christine Grimaldi reported, not only did the Department of Justice already decline to challenge the Texas injunction back in March, they filed last week for a voluntary remand and stay in the case that would allow the HHS to revise the regulations.

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And it doesn’t exactly give transgender people faith in the HHS that Roger Severino, Trump’s appointment to head the HHS Office of Civil Rights, has already publicly opposed the Obama administration’s interpretation of Section 1557 while working at the Heritage Foundation, as The Daily Beast previously reported. Nor does it thrill them that Charmaine Yoest, Trump’s pick for HHS assistant public affairs secretary, once called transgender people “creatures” on her blog.

“It’s almost as if President Trump is trying to find people who say the most mean, spiteful, hateful things about transgender people to fill roles in his administration,” NCTE Executive Director Mara Keisling said in a press statement on Yoest.

NCTE did not immediately respond to The Daily Beast’s request for comment on this story. However, they have officially outlined their concerns with transgender health care under the AHCA in a Medium post. And apart from issues of affordability and Medicaid funding—which would disproportionately affect transgender people given their high poverty and unemployment rates—two issues, in particular, stick out.

The first is the possibility that gender dysphoria, the psychiatric term for the “conflict” between a person’s actual gender and their birth-assigned gender, could be considered a pre-existing condition that would raise premiums. Transgender people often rely on this diagnosis to access transition-related medical care.

The second is a provision in the AHCA that blocks patients from using Medicaid at Planned Parenthood health centers. Thirteen percent of respondents to the U.S. Transgender Survey said they were covered by Medicaid. And as The Daily Beast reported earlier this year, Planned Parenthood may, in fact, be the largest provider of transition-related medical care in the country with health centers in at least 16 states offering hormone therapy to transgender patients.

“By gutting pre-existing conditions, Medicaid, and funding for Planned Parenthood, [the AHCA] is especially harmful for transgender Americans and their families who already face serious barriers,” said Keisling in a statement.

Bathroom protections and other non-discrimination measures remain important civil rights issues for transgender people. Staying alive is even more vital.