Issue:  Vol. 48 / No. 8 / 22 February 2018

Community pushes for TG health coverage


Flashback to April 2001: Transgender advocates Dr. Joan Roughgarden, Daniel Green, Jennifer Wolcott, Theresa Sparks, Veronika Cauley, and Sally Ramon celebrate the Board of Supervisors' vote to provide coverage of medical needs for transgender city workers. Six years later, progress in other parts of the country has been slow. Photo: Jane Philomen Cleland
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Recently, an employee of an East Coast LGBT health organization was asked to assist in preparing one of the organization's trans-related grant proposals. Just weeks before, he said, a male co-worker was denied insurance coverage for a medically necessary procedure that is routinely covered for other subscribers. The reason for the denial was that the man has a transsexual history, and the insurance policy excluded anything that could be construed as related to sexual reassignment – in this case, a hysterectomy, a procedure often sought by transsexual men for nonfunctioning organs and related pelvic pain, and typically covered for women without question.

The man, who was in dire need of the procedure, eventually had to hire an attorney to help him secure proper care. But the irony of such an exclusion was not lost on the man's co-workers, whose organization is known for providing healthcare to the transgender community.

"I had to write back to my organization and say I was sorry, but I could not help to bring in more funds for a place that makes a lot of its money on the perception that it's trans-inclusive,Ó said John, an HIV prevention worker for the organization. "I would hate to have to find a lawyer before I found a doctor."

John was one of several people who declined to give his last name and asked that his organization not be identified for this article. Many LGBT organizations are currently grappling with how to handle transgender health benefits, and identifying these groups could upset the delicate nature of negotiations, advocates said.

Six years after the city of San Francisco passed its groundbreaking transgender healthcare benefits package, progress across the country has been somewhat slow to follow. As a result of the 2001 legislation – which mandated trans healthcare and sexual reassignment coverage for all transgender city employees in need – regional private insurance companies such as HealthNet, Blue Cross, and Kaiser developed the infrastructure that would allow them to offer such benefits to other employers' healthcare plans, and some employers – like the entire University of California system – quickly adopted packages with full coverage. Other employers – from the Washington, D.C.-based Human Rights Campaign to corporate entities like Microsoft have offered full hormonal and surgery coverage to their employees through "self-insuring," or what amounts to a separate fund for employee health costs.

But unlike the surge in domestic partner benefits that was seen nationwide after San Francisco passed its landmark 1996 equal benefits ordinance – which mandated that companies doing business with the city provide equal health benefits to their employees with same-sex partners – the issue of transgender healthcare remains misunderstood – both in terms of medical necessity and potential cost. And even employees who do have trans-related healthcare may find that adequate care remains difficult to secure.

The biggest problem, according to Assemblyman Mark Leno (D-San Francisco), who authored San Francisco's legislation when he was a city supervisor, is that the insurance industry itself remains broken. Discriminatory exclusions and exorbitant costs mean "so many small employers have a problem trying to give any of their employees coverage," though he added that San Francisco has proved that transgender benefits as part of an existing health plan need not be cost-prohibitive.

According to San Francisco Human Rights Commission investigator Marcus Arana, in the first four years after the city's transgender benefits passed, the city's own health plan (managed by United Healthcare) collected an extra $1.70 per month per insurance member for a total of $5.6 million, and paid out just $183,000 for 11 transition-related surgeries. Data from the private insurers' HMO plans is more sparse; HealthNet reported paying $3,300 for hormones and psychological care during a one-year period between 2004 and 2005, for 14 of its transgender members.

But Leno also said the sensationalized messages surrounding trans-related healthcare continue to misinform the general public about why it is a necessary benefit that insurance companies should offer and employers should adopt.

"It's all about education. There has been a lot of evolution with regard to how people understand the transgender community today, and I'm pleased that our local ordinance was a part of that evolution," Leno told the Bay Area Reporter. "But I remember so clearly – as much as we worked with media back then – every headline read 'City to pay for sex-change operations.' I told them, that's not what this is about: if you were a non-trans employee of San Francisco and needed hormonal treatment, a mastectomy, or a hysterectomy, you would get that coverage, and yet a transgender employee in need of that identical medical care was being denied."

Before San Francisco's ordinance – and later, a California bill by former Assemblyman Paul Koretz (D-West Hollywood) that prohibited transgender insurance discrimination (without mandating coverage for specific procedures) – it was much more common, said Leno, for transgender people to routinely be denied everything from counseling to annual screenings.

"Prior to the legislation, if a transgender individual had some horrible events such as losing a loved one or surviving a traumatic violent crime, they might go to seek counseling or psychiatric care, but if that individual even mentioned the word 'transgender' – and how could one not – then none of that care would be covered because it would have been 'related' to being transgender. It affected all sorts of care that every human being needs at one time or another."

Removing trans exclusions from a policy, advocates have noted, rather than giving "extras" to the trans population, often simply levels the field.

Yet sexual reassignment itself is indeed deemed medically necessary for those transsexuals who cannot otherwise function in society.

Assemblyman Mark Leno. Photo: Jane Philomen Cleland

"Some people liken transgender surgeries to a nose job, but that's not what this is. This is a diagnosed situation and there is prescribed care for it," said Leno.

John agreed, noting that insurance companies frequently cover gender-related reconstruction for the social comfort of their non-trans members.

"If I asked my fellow gay male employees, 'If you lost your penis, would you expect your company to do everything it could to help you out with that?' they would of course say yes," said John. "But I think people have a hard time granting the same depth of need and urgency to someone who has never had the experience of having what they need."

Covering the gap

It's clear to Dr. Nick Gorton, a physician at Lyon-Martin Health Services, that many employers – particularly LGBT organizations – would offer transgender health benefits if they believed they could.

But there do remain some cost obstacles for LGBT employers, he said, because insurance companies will offer rate quotes for benefits based upon the likelihood of employees accessing those benefits.

"If you go to the insurance company and tell them you're a builder in bumfuck, California, what are the odds this employer is going to have a trans employee? Pretty slim, so adding the policy might be an extra $100 per employee per year," said Gorton. "Whereas, with an LGBT organization, the likelihood is pretty high that you will have a couple of trans employees, so it may cost something like an extra $3,000 per employee a year."

Many LGBT organizations suddenly found themselves in similar situations in the 1990s, when trying to secure coverage for new and expensive HIV treatments.

Other obstacles to LGBT organizations adopting trans benefits, said John, is that some policies and/or surgeons exclude HIV-positive individuals from obtaining this care, "based upon an outmoded view of HIV as well as transsexuals," he said. "No GLBT health agency like mine would be so callous or stupid to support that with its dollars."

Gorton said one way smaller employers are offering this benefit to employees is by maintaining a separate fund for its transgender employees; "They're saying, 'OK, we're just going to pay for this,' and are finding insurance companies to handle the hormones while setting aside a certain amount of their own money, with a spending cap, for surgeries."

It's what HRC's Daryl Herschaft calls "self-insuring on that one item." Larger companies, like Microsoft, tend to self-insure on all items because there are enough employees and company funds to assume the risk that insurance companies charge fees to take on.

"We are sympathetic to the smaller employer," said Herschaft. "But for many companies, self-insuring on that item really won't break the bank."

While praising the practices of HRC as an employer, Gorton takes issue with HRC's current method of evaluating corporate America's progress on trans coverage. He said that HRC's Corporate Equality Index currently evaluates "transgender wellness benefits" on a scale that rates employers with minimal benefits as equal to employers with full trans-related coverage.

Herschaft agreed that HRC's current system for trans benefits "has intentionally included not only sexual reassignment benefits but wellness benefits, so that companies can begin to look at this stuff and dialogue internally." But he added that trans benefits are a new aspect of the equality index, and that he expects HRC's evaluation criteria to change over time.

"We've seen a dramatic rise in the companies looking at transgender benefits for their employees, and we have every intention of continuing to raise the bar on this issue," said Herschaft. "We have the ear of hundreds of major employers who are very much in tune to what the index looks like."

Another obstacle of transgender healthcare coverage is that it's difficult to find sexual reassignment surgeons to work with insurance companies, said the Human Rights Commission's Arana, who is a transgender man himself.

"One of the biggest problems is that even though HMOs are ready to offer this benefit, very few doctors are ready to accept HMO payments," said Arana. "Anecdotally, we've heard complaints that doctors have went ahead and done the surgeries, and then the city health plan paid them 20 cents on the dollar, and they don't ever want to work with the city again. There's no reason for them to take less money than they get from clients walking in with a checkbook."

But there are solutions, said Arana, who noted that Dr. Toby Meltzer, a well-known sexual reassignment surgeon in Arizona, is training Northern California Kaiser doctors on genital surgeries so that Kaiser will become a "center of excellence" in its own right.

"We need more doctors to do this," Arana said, adding that some local surgeons who make a lot of money from the trans community have expressed no interest in contracting with the city to improve its transgender benefits system.

Also important, said Arana, is how employers – particularly LGBT employers – handle this issue. If more of them take the lead and ask their insurance carriers to remove transgender exclusions, more doctors will accept insurance money for trans-related procedures, most of which "aren't even all that specialized," he said. "These procedures were not created for us."

"There will need to be some activism on this issue," said Arana, "and it should come from more LGBT organizations."

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