Removing exclusions is an important part of ensuring access for transgender people to a variety of medically necessary services. Similar to everyone else, transgender people need acute care when they are sick and preventive care to keep from becoming sick, including services that are traditionally considered to be gender-specific, such as Pap smears, prostate exams, and mammograms. Transgender people may need a mix of such screenings: Medically necessary preventive screenings for a transgender woman, for example, may include both a mammogram and a prostate exam.
Transgender people also need access to medically necessary care related to gender transition. In fact, access to transition-related services is integral to the meaning of gender-identity nondiscrimination in insurance. For many transgender people, their identity—the essence of who they are—is closely connected with a medical condition. The medical diagnosis that correlates with a transgender identity is most frequently referred to as gender identity disorder, or GID, which the American Medical Association, the American Psychiatric Association, and the World Health Organization all recognize as a serious medical condition. According to the American Medical Association, “GID, if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death.” As such, treatments for this condition cannot be considered cosmetic for transgender people.
According to the “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,” maintained by the World Professional Association for Transgender Health, gender transition does not constitute a uniform, fixed-treatment protocol that is appropriate for every transgender person. Instead, as discussed above, the treatments that may be involved in gender transition include a range of mental-health and medical and surgical procedures that are the same services provided to nontransgender people for a variety of conditions.
Gender-identity nondiscrimination is thus not a mandate to cover a specific service or set of services. Rather, it is a reflection of the understanding that what is at stake for transgender people in insurance coverage is not simply a failure to cover any particular treatments for a particular diagnosis but a broader failure to provide access to medically necessary care for a vulnerable population that is uniquely dependent on medical treatments to realize their identities and to live healthy, authentic lives.
The question of costs
In resisting compliance with federal and state law regarding gender-identity nondiscrimination, some claim that premiums will rise if transgender exclusions are eliminated. Research has clearly debunked this cost argument, however. The California Department of Insurance, for example, released an economic-impact assessment in April 2012 comparing the costs and benefits of a California law prohibiting insurance discrimination against transgender people. The department concluded that removing exclusions that target transgender people has an “immaterial” impact on premium costs and that “the benefits of eliminating discrimination far exceed the insignificant costs.”
Inaccurate actuarial projections about the costs associated with gender transition and the size of the transgender population underlie many inflated estimates of the cost of equal coverage. The city of San Francisco, for example, charged $1.70 in additional monthly premiums for each enrollee when it removed transgender-specific exclusions from the coverage it offers to its employees and introduced a rider for medically necessary care related to gender transition in 2001. Over the next five years, the city collected $5.6 million in excess premiums and paid out only $386,417 on 37 claims. As a result, the premium surcharge was dropped in 2006, and the city affirmed coverage for medically necessary transition-related care as part of its core benefit package.
The experience of private employers overwhelmingly concurs. Kaiser Permanente recently removed transgender-specific exclusions from its employee plans and anticipates no resulting change to the cost trends of its health plans. The 2013 Corporate Equality Index reports that 25 percent of Fortune 500 companies, including giants such as Google, Nike, and the Coca-Cola Company, offer coverage with no transgender- specific exclusions.
What’s more, providing access to transition-related care improves health outcomes for transgender people, which may result in cost savings. The California Department of Insurance assessment found that eliminating gender-identity discrimination in health insurance plans reduced suicide risk, lowered rates of substance abuse, improved mental-health outcomes, and increased adherence to HIV-treatment regimens for many transgender patients. And since transgender people, like millions of other Americans, will benefit from the expansion of access to coverage under health reform, ensuring that transgender people have access to the services they need to stay healthy is both common sense and good financial sense.
The health care services that transgender people need are neither special nor suspect, and the growing body of legal protections prohibiting insurance discrimination against transgender people does not impose coverage mandates. Instead, federal and state laws are finally grappling with the consequences of discriminatory exclusions that arbi- trarily deny transgender individuals equal access to the medically necessary health care services they need to lead full and healthy lives. And as studies of the economic conse- quences of removing transgender exclusions show, eliminating insurance discrimination against transgender people costs practically nothing. Rather, it’s turning a blind eye to discrimination that racks up both financial and human costs.
Kellan Baker is the Associate Director of the LGBT Research and Communications Project at the Center for American Progress. Andrew Cray is a Policy Analyst with the project.