As transgender individuals face mounting attacks on their basic rights, the U.S. House of Representatives passed the Equality Act at the end of February 2021. Passage of the Equality Act would provide explicit anti-discrimination protections for LGBTQ+ people in workplaces, federally funded programs, housing, education, and other public spaces. Now in the Senate, the bill is being hotly debated. While the bill is designed to rectify longstanding and well documented transphobic discrimination, the bill’s opponents are aggressively scruitinizing the benefits trans individuals stand to gain. Specifically, their wrath has focused on the provision that would strengthen trans individuals’ right to gender-affirming healthcare.
Ironically, the sweeping changes terrifying conservative lawmakers are unlikely to occur. The Equality Act will have more symbolic than tangible impacts on healthcare access. Since the bill lacks specific language which guarantees gender-affirming care to trans patients, trans individuals can still be denied care under the Equality Act, but now they have the law slightly more on their side should they take it to court.
Trans folks can be denied access to care if they’re Medicaid beneficiaries. This is because states can choose what services their Medicaid programs provide. Right now, 12 of 50 states have language denying Medicaid beneficiaries from accessing gender-affirming care by either explicitly or implicitly delineating those services under the category of “cosmetic and experimental surgery,” which isn’t covered by Medicaid. And while passing the Equality Act would require all healthcare providers to adminster basic care to transgender patients, it wouldn’t explicitly guarantee transition-related care because these categories of treatment would still not be covered.
For comparison, even after the Affordable Care Act (ACA) required states to provide gender-affirming services under Medicaid in 2016, most states were slow to adjust their Medicaid policies accordingly. In many states, explicit denial of care was replaced by underhanded categorization of many necessary surgeries as “cosmetic,” effectively circumventing that aspect of the ACA. In the absence of a clear requirement for coverage of gender-affirming care, it’s likely that many organizations will still try to discriminate against trans folks on the grounds of religious or moral objections as they did with the ACA.
However, this issue reaches beyond the 13% of trans individuals covered by Medicaid. The Equality Act would only guarantee access to care for Medicaid beneficiaries, and other trans people — particularly those covered by private insurance — would still be at risk for discrimination. Private insurers aren’t held to the same standards as federally funded programs like Medicaid, so they can place exclusions (provisions that eliminate health-care coverage for particular services) on gender-affirming surgeries. Right now, private insurers categorize gender-affirming surgeries as experimental or aesthetic, which makes necessary healthcare unaffordable for most trans people.
UR students can count themselves lucky that the school-sponsored insurance, provided through Aetna, has covered transition-related surgery and some services since 2014. While the policy could be improved to more accurately address transgender care, it’s still better than some other public or private insurance policies.
The importance of gender-affirming care for the health of transgender individuals cannot be overemphasized. Gender-affirming care, including hormone therapy and gender confirmation surgery (GCS), is agreed upon by professional medical societies as the recommended treatment to alleviate depression, anxiety, and stress brought on by improper gender expression and to improve quality of life for trans persons. Additionally, studies have shown GCS has an approximately equal rate of complications as similar surgeries, and patients post-surgery are highly satisfied, with regret rates hovering around 1%.
If the Equality Act is passed, trans and non-binary individuals would become more empowered advocates for their health, but contrary to its detractors’ concerns, it won’t necessarily lead to widespread access to gender-affirming care. Federal legislation guaranteeing access to gender-affirming therapies and surgeries for transgender patients is also necessary to ensure that transgender and gender nonconforming folks get the care they deserve.
