January 4, 2021
Commentary: Barriers and opportunities to improve access to care for transgender people
Researchers discuss recent federal court rulings and policy considerations that could shape health coverage and access to gender-affirming care for transgender people.
Nearly two million American adults identify as transgender. Although gender-affirming care, including surgeries and hormone therapy, can be life-saving for transgender people, access varies by income and insurance coverage.
In a recent podcast interview with Stephen Morrissey of The New England Journal of Medicine (NEJM), Daphna Stroumsa, M.D., M.P.H., clinical lecturer in obstetrics and gynecology at U-M Medical School, discusses their NEJM perspective article about barriers and opportunities to improve access to gender-affirming care for transgender people.
Specifically, Stroumsa and co-author Anna Kirkland, J.D., Ph.D., Arthur F. Thurnau Professor of Women's and Gender Studies at U-M College of Literature, Science, and Arts, examined the case of Toomey v. Arizona, which challenges whether a health plan for state employees can categorically exclude coverage of gender-affirming surgery.
"We have some data on [how common it is for health plans in the U.S. to exclude gender-affirming care], but certainly from clinical experience, it is pretty common," says Stroumsa in the NEJM interview. "The exclusion happens through a variety of mechanisms. Some insurances have a blanket exclusion of transgender or gender-affirming-related care, while others exclude through coverage denials."
Stroumsa notes how a recent ruling by the U.S. Supreme Court in Bostock v. Clayton County held that Title VII of the Civil Rights Act of 1964, which protects employees against discrimination based on sex, includes discrimination based on sexual orientation and gender identity. This landmark decision is likely to influence the Arizona case and similar cases related to employer-sponsored coverage for gender-affirming care.
"This could help open the door to all transgender people for increased protection and increased access through their health insurance if it's employer-based, but does not necessarily affect people whose access to health care is not through employer-based insurance,” explains Stroumsa.
For those covered through Centers for Medicare & Medicaid Services, Section 1557, the nondiscrimination section of the Affordable Care Act, has been interpreted differently by recent federal government administrations, so discrimination protections for transgender people are currently in litigation and up in the air.
In their article, Stroumsa and Kirkland outline several policy considerations to increase protections and improve access to gender-affirming care for transgender people, including introducing a new anti-discrimination law that more clearly includes discrimination based on gender identity and sexual orientation.