COVERAGE

FOR
EVERYONE:
THE US HEALTH
INSURANCE SYSTEM'S
IMPACT ON TRANS AND
NONBINARY LIVES

PLCY 365
GRAHAM BOOTH, HANNAH GAHAGAN,
MORGAN PESTYK, AND SARAH SPRANGLER
TABLE OF CONTENTS
INTRODUCTION................. 1
OPPRESSION
HISTORY: NONBINARY AND INTERSEX... 1
TIMELINE: TRANS INDIVIDUALS............... 2
BEHAVIOR FACTORS............................. 3
HEALTHCARE
HISTORY.............................................. 4
HEALTHCARE TODAY............................ 5
EXISTING GAPS IN COVERAGE..............
6
ALTERNATIVES
AVENUES FOR REFORM........................ 7
PUBLIC OPINION..................................
8
EFFECTS OF UNIVERSAL SYSTEM........... 9
RECOMMENDATIONS......................
10
REFERENCES............................. 11
Introduction
Although the term 'transgender' itself is contemporary, gender fluidity and patterns which we associate
with a transgender identity have always been a part of life in North America (Beemyn, 2014). However,
the relative cultural inclusion of trans individuals in Native American cultures starkly contrasts with the
discrimination trans individuals experienced within the White-dominated American colonies (Beemyn,
2014). Lacking institutional roles for trans individuals in their own societies, these communities
frequently applied charged labels of ‘sodomites’ and ‘hermaphrodites.’ Through the twentieth century,
historians repeated these mistakes, interpreting these individuals as ‘homosexuals,’ ‘transvestites,’ or
‘berdaches.’ (Beemyn, 2014)

This report unmasks such discrimination faced by trans and nonbinary individuals today, and shows
how the U.S. healthcare system specifically fails to properly serve their needs. The medical
discrimination of trans and nonbinary individuals is an incredibly salient policy issue. The report
explores potential policy alternatives, ultimately advocating for a universal healthcare system.

History of Nonbinary and Intersex

Oppression in America
The oppression and acknowledgement of intersex individuals in America most notably begins in
the medical ecosystem of the 19th century. Early medicine prescribed instructions for patients to
assume normal gender roles of the sex they most "looked like"; surgeries or medicines were either
performed well into adulthood, or not at all until the 20th century (ISNA.org).

In the 1950s. researchers at Johns Hopkins University created the "multi-disciplinary approach" as
a means of handling intersex patients in childhood (ISNA.org). This method tried to prove that a
person could conform to a gender binary system of behavior if a singular gender role was adopted
from birth. However, there were many cases that proved this method caused not only physical
damage, but severe mental trauma for the person who underwent such dramatic surgery without
giving their consent (ISNA.org). Later in the 90s, activist and awareness groups would form (such as
the Intersex Society of North America) to inform the public on the harmful nature of Intersex
Genital Mutilation and educate the masses on the falsities of a binary gender system (ISNA.org).
While awareness has spread considerably over the years, it should be noted that these harmful
surgeries or treatments can still be practiced today by private physicians.

1
 Timeline of Historical Events for
Trans Individuals
The first recorded sex change surgery
was conducted in Germany by Hirschfeld’s
Instituted for Sexual Science in 1931
(Beemyn, 2014)
American endocrinologist Harry Benjamin
pushed against the medical framework in the
United States that saw biological sex as the
immutable defining aspect of someone’s
gender. Benjamin was the first to use the
term ‘transsexual’ and helped shift the
narrative to the view that gender identity
is the dominant element of someone’s
gender. (Beemyn, 2014)
After police raided a gay club in New York City,
the June Stonewall Riots broke out as the
LGBTQ community joined in several days of
demonstrations protesting
discrimination).
Renee Richards, a trans woman, was
barred from playing tennis in the U.S.
Open (Geidner, 2019). In Richards v. United
States Tennis Association in 1977, she won
an injunction under New York state law to
compete in the that year’s Open. (Geidner,
2019)
The American Psychiatric Association
added ‘gender identity disorder’ as a
classification for transgender individuals.
Gwendolyn Smith started the first
Transgender Remembrance Day to honor
the memory of transgender individuals who
have been lost to bigoted violence
(Milestones in the American transgender
movement, 2015).
The Girl Scouts of Colorado welcomed all
children who identified as girls. (Milestones
in the American transgender movement,
2015)
1931
Michael Dillon became the first female-
1939 assigned individual to take testosterone
for the purpose of transforming his body.
In 1952, Christine Jorgensen, an Army
1950-1960 private from the Bronx, traveled to Denmark
to undergo a genital transformation
surgery, becoming the first American citizen
to do so (Milestones in the American
transgender movement, 2015). She brought
the topic into American conversation and
served as a role model for other trans
individuals (Beemyn, 2014).
1969
Sylvia Rivera and Marsha Johnson  formed
the Street Transvestite Action
Revolutionaries (STAR House) as an
1970 advocacy group and shelter in New York
(Milestones in the American transgender
movement, 2015).
1976
Minneapolis became the first city to ban
1977 discrimination against trans individuals
(Milestones in the American transgender
movement, 2015).
1987 Minnesota became the first state to ban
discrimination against trans individuals
1993 (Milestones in the American transgender
movement, 2015).
1999 California became the first state to
mandate transgender healthcare
2005 coverage. (Milestones in the American
transgender movement, 2015)
The American Psychiatric Association
2012 replaced the label of ‘gender identity
2013 disorder’ with that of ‘gender dysphoria.’
(Milestones in the American transgender
movement, 2015)
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 Behavioral factors that contribute to
oppression
Unfortunately, trans individuals still face discrimination in employment,
housing, public accommodation, and incarceration (Schwartz, 2020).
Indeed, one survey showed that 47% of transgender people have
faced discrimination in hiring, promotion, or job retention. Because
there is no federal law that explicitly protects trans individuals, the
federal government has creatively withheld funding to help eliminate
bigoted state ‘bathroom bills.’ (Schwartz, 2020)
Unwilling identity outing in healthcare settings often happens
by unknowing/ignorant healthcare professionals (Wagner). The “Findings indicate that
practice of establishing one’s “alternate” identity is done by subtle discriminatory
many healthcare professionals in order to provide a holistic
healthcare experience. However, this can be done quite
experiences may be
clumsily and result in putting a trans or non-binary person in encountered most
an uncomfortable position that keeps them from seeking help
frequently [by Trans
in the future.
patients]” (Vermeir).

“When compared with cisgender individuals, non-binary/genderqueer people:

had a higher risk of violence and employment discrimination
were higher isolated and unhappy
had more psychological problems and higher percentage of suicidal ideation” (Scandurra).

Phal-O-Meter
One tool currently used In
health care to determine sex
at birth is the Intersex Society
of America's "Phall-O-Meter".
Children born with genital
length between the male and
female parameters are
recommended for surgery.

However, it is important to consider the

structural features that are perpetuating
oppression of trans/NB people in US. . . 3
 History of US Healthcare
How Minority Groups have been Excluded from the Start

Our health care system has long since failed to serve all populations equitably and
provide adequate coverage - particularly through the health insurance system. Health
insurance is a relatively new form of insurance. Up until the early 1900s, health services
were paid for out of pocket. Major shifts in the medical field emerged; demand for
higher quality providers and hospitals increased and facilities were modernized through
licensing and technology. Medicine also became more accepted as a branch of science,
elevating it to a new academic standard. As a result, health service costs increased.
This introduced considerable financial strain on
both consumers and providers during the Great
Depression. In response, Baylor University
Hospital began offering the nation's first prepaid
health plan - a precursor to health insurance.
Similar plans were formed across the country,
organizing under nonprofits known as 'Blue
Cross' and 'Blue Shield'. The success of the Blue
plans prompted for-profit insurance companies
to enter the health insurance sector. Around
World War II, companies began offering health
insurance coverage to employees in lieu of higher
pay to offset financial burden. Employers rapidly
became a primary source of health insurance in
the US. This system private health Insurance
providers covered a massive number of
people, but remained inaccessible to certain
populations.

In the mid-20th century, Americans discovered clear gaps in health insurance coverage.
Legislation was proposed that would ensure universal health coverage for Americans, but
was quickly squashed by physician lobbyists out of concerns for drops in reimbursement
rates. In 1965, a compromise was made; Medicare and Medicaid were formed to offer a
public option to elderly and low income populations, respectively. Since their formation,
Medicare and Medicaid have evolved dramatically to include more vulnerable
populations. Passage of the Affordable Care Act (ACA) in 2010 has led us to our current
health insurance system (Moseley, 2008).
4
 US Healthcare Today
The Affordable Care Act
The ACA included 3 primary goals to increase coverage in the US: to provide tax credits for low
income individuals, expand Medicaid eligibility, and support innovation to lower health care
costs. The Department of Health and Human services uses the Federal Poverty Line (FPL) as a
relative measurement of income to determine eligibility for tax credits; those whose income is
below 400% of the FPL can receive credits. Similarly, all individuals with income below 138% of
the FPL are eligible for Medicaid under the expanded program (HealthCare.gov, n.d.). The ACA
effectively increased access to health insurance coverage in the US, but did not ensure coverage
for all Americans. 
Since the ACA’s enactment,
the number of uninsured
Americans has decreased
from 46.5 million to 26.7
million (Tolbert et al., 2019).
Although this is a massive
success in addressing gaps in
coverage, many people are
still uninsured and rates of
uninsurance have begun to
rise. Insurance status has
been found to be a major
determinant of health in
Americans.
Uninsured individuals are less likely to receive preventive health services and experience decreased
access to care (Garfield et al., 2019). Our current system has left clear gaps in coverage that
perpetuate these poor outcomes. The ACA did not require all states to expand their Medicaid
program, allowing them the option to maintain the previous eligibility requirements.
Currently, 14 states have yet to expand
Medicaid. In unexpanded states, low income
people face considerable barriers in
qualifying for Medicaid - those with income
below 40% of the FPL can qualify for
Medicaid based on income. However, those
with income below 100% of the FPL are not
eligible for premium tax credits. This leaves
people between 40% and 100% of the FPL
ineligible for both Medicaid and premium tax
credits, creating a coverage gap. Recent
reports have found that over 2 million
uninsured Americans fall into this gap
(Garfield et al., 2020).
5
 Existing Gaps in Coverage
On May 13, 2016, the HHS Office for Civil Rights affirmed that any insurance company
receiving federal funding is bound by Section 1557 of the ACA, which applies existing
anti-discrimination laws to health coverage (U.S. Department of Health and Human
Services, 2020). Even so, there is no mandate that they cover any particular
transition-related care or surgery (even if ‘medically necessary’), but rather that the
services they do cover are offered in a nondiscriminatory manner. (Norris, 2020)

Medicare today covers all routine preventive care, regardless of gender markers. Pelvic
exams, mammograms, and prostate exams are covered under Medicare as long as
they are clinically necessary (National Center for Transgender Equality, 2020). Medicare
covers hormone therapy and transition-related surgery on a case-by-case basis if it is
deemed “medically necessary.” (National Center for Transgender Equality, 2020).

Typically, the insurance companies

determine medical necessity. Doctors
can make an argument for why
something should be considered
medically necessary but insurance
companies (which themselves have
monetary incentives to deny coverage)
currently have the final say.

For hormone and transition-related surgeries, ‘medical necessity’ is most frequently

granted when it is determined that not doing so would trigger mental health crises.

However, if the insurance company is

publicly funded (Medicaid, current
Medicare, the VA, Medicare For All, or any
other government health care option),
then the administering entity (the
insurance company in a Medicare setting)
makes a determination, but there is the
opportunity to appeal to an administrative
law or district court judge.

6
 Avenues for Reform

No Change
It's important to acknowledge the effect that no change whatsoever would
have on these especially vulnerable populations within the U.S. As
mentioned previously in this report, a person only has as much access to
medicine as their insurance company will allow. This brings up some
incredible issues that many trans, nonbinary, and intersex people must face
when arguing for the validity of their medical needs. In 2015, the National
Women's Law Center released survey results that showed 25% of
respondents experienced issues with their health insurance that were
somehow related to their gender expression or identity (Temple, 2016). If
we do not look to actively implement changes into our current health
system, it's likely that this lack of coverage will not cease.

Partial Reform: Public Option

This public option is the middle ground between Medicare for All and the
current system we have now. This partial reform would give citizens the
opportunity to be insured by the government, but does not eliminate
private insurance, which would likely involve expanding the ACA coverage
to all citizens. Politically, this plan would preserve the choice of an individual
to remain privately insured if wanted, but would allow those not able to pay
for private insurance to be covered. Some cons of this is that people can
still fall through the cracks and remain uninsured. As previously mentioned,
insurance companies determine medical necessity, so trans and nonbinary
patients that remain with their private insurer for a multitude of reasons
can still be denied the procedure they want. This is the current plan
favored by Biden.

Universal Healthcare
A universal healthcare option, commonly referred to Medicare for All,
would allow all U.S. citizens to be covered by a single national health
insurance program. All Americans would receive comprehensive
health coverage from the government. Under the progressive lefts’
plan, the government-run insurance would include dental, vision, and
long-term care, minimizing the use of private insurers (Zeballos-Roig,
2020). In Sander’s plan, patients would not be charged co-pays, co-
insurance, or deductible and would be financed by new taxes and
argued the healthcare savings would offset the tax increase.
Employers would no longer have to spend to cover their employees,
but would be taxed slightly more. Sanders also plans to give the
government more power to negotiate with drug companies to secure
lower prices. 7
 Public Opinion on Healthcare Reform

In polling conducted in early 2020, it was Democrats

M4A
determined that a majority (56%) of
Americans favor a M4A system, while a
larger percentage (68%) favor a
government-administered public option.
Democrats favor both proposals with high
percentages, while only one in four
Republicans support a national M4A plan
and four in ten favor a public option Public Option
(Lopes, 2020).  Favor

Oppose
Republican
M4A Public Option

Under a national single-payer

system, all Americans would be

25%
insured which would likely lead
to greater health care
consumption with services
currently paid for by uninsured
individuals to increase by 25
percent (Liu & Eibner, 2019).
The American Medical Association,
which is the biggest physician group in
the US, opposes Medicare for All due to
the potential cutting of doctors
payments and increase in demand for
healthcare (Zeballos-Roig, 2020). 8
 How universal healthcare could impact
trans/NB/intersex healthcare
In one survey, 55% of trans people reported being
denied coverage for gender-affirming surgeries
(Jones and Zim, 2019).

“People are pumping silicone, which is incredibly dangerous, or

there are hormones that they might acquire from non-
pharmacy sources. That's going to put them at a huge risk for
complications and potentially ED visits, which we already know
are very expensive and a burden to the health care system.”
- Dr. Caitlin Leach, clinical pharmacist and lecturer at the School of
Pharmacy at University of Maryland

A universal healthcare model would allow for accessibility to healthcare

services that members of trans, non-binary, and intersex communities have
historically never known in the United States. With no private companies
able to deny coverage, doors to life-altering medicine can open for these
groups in safe and available ways. Not only will this result in easier access
to medicine, but it is also likely to eliminate the need for at-home remedies
or shady practices or surgeries performed by uncertified physicians that
can be incredibly dangerous and risky. In providing care that is trustworthy
and consistent, we believe lives of all affected groups can drastically
improve.

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 Recommendations
For a single-payer model to truly benefit these communities, the system
must cover a range of therapies, procedures, and medicines.
This includes, but is not limited to:
The complete coverage of hormone replacement therapy, including doctor’s visits as well as the
hormones themselves
Any necessary blood work or tests required to monitor the health of the patient seeking this care
Any and all surgeries transgender individuals (or their representative with making ability) deem
necessary to improve their quality of life***
Feminizing vaginoplasty ***Due to the
Masculinizing phalloplasty / scrotoplasty elimination of privatized
healthcare, the terms
Metoidioplasty (clitoral release/enlargement, may include urethral lengthening)
"medically necessary" vs.
Hysterectomy "cosmetic" would not be
Masculinizing chest surgery ("top" surgery) relevant in the case of
trans, non-binary, or
Facial feminization procedures
intersex patients.
Reduction thyrochondroplasty (tracheal cartilage shave)
Voice surgery
Any counseling service or therapy that an individual may choose to seek out regardless of whether or
not an individual reportedly has “gender dysphoria”.
Specific necessary medical procedures that some intersex children may need at birth: including
"endocrinological treatment of a child with salt-wasting congenital hyperplasia, or surgery to provide a
urinary drainage opening when a child is born without one” (ISNA.org).

We also recommend that several out-of-date policies/procedures be banned or changed.

Intersex Genital Mutilation should by no means be performed on any intersex child and healthcare
professionals should be banned indefinitely from performing this dangerous surgery.
Under no circumstance should a diagnosis of gender dysphoria be required for a transgender patient
to receive therapies/procedures.

Education:
Our recommendations for how believe the system must be improved upon to improve everyone's
quality of life extends to other healthcare institutions that we believe are essential to making
healthcare accessible and safe for trans and non-binary individuals. In order for a single-payer
system to truly benefit trans and non-binary lives to the fullest extent, medical schooling models
must expand curriculum to account for the specific knowledge and information needed to properly
treat communities that many professionals are not familiar with. This curriculum must expose future
healthcare professionals to LGBTQ+ specific healthcare practices, as well as spawn a sensitivity
training that promotes one of the core tenets of the Hippocratic oath: to help the ill to the best of
one’s ability. By training and educating the future of the medical field to be aware of these specific
needs, a level of preparedness can be achieved that provides a foundation for optimal care and
safety for patients.
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References

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