A lot has changed for Kallie Winners since she first sought medical treatment to begin her male-to-female transition in 2011. Winners, who spent 10 years in the military, initially visited Denver’s VA Medical Center where she quickly discovered doctors had not been trained to treat transgender patients. She was ultimately denied care.
“It’s hard to describe to somebody who’s not transgender what it’s like to live your entire life in a body you don’t recognize,” she said. “To go to the place where I felt I could get care, which was the VA, and to be denied was awful. It was so awful, I didn’t step foot in a VA for the next three years.”
Even though she was finishing college, Winners ended up paying for her transition out of pocket at an average annual cost of $1,800.
Today, Winners is employed as an engineer and has health insurance through Kaiser Permanente. The insurer gives transgender clients a list of preferred providers trained in transgender-specific care.
“The biggest change is actually having a primary care physician that’s not only educated about transgender health care but passionate about advocating for transgender people,” Winners said.
Winners’s latest health care experience is indicative of major ground won by transgender people and their advocates. Even so, her previous experience of exclusion still persists for many in the transgender community.
A new report from LGBTQ rights organization One Colorado entitled Transparent sheds light on the successes and challenges transgender Coloradans have found in the rapidly evolving health care system. The passage of the Affordable Care Act (ACA or Obamacare) and Colorado’s decision to expand Medicaid led to some of the more radical changes in accessibility.
“The ACA includes gender identity in its nondiscrimination clause,” said Leo Kattari, the Health Policy Manager at One Colorado, noting that state statute makes a similar prohibition.
“At the state level, it gave those of us in Colorado the opportunity to work with the Division of Insurance to release a bulletin saying that exclusions in health care policies targeted to transgender people is discrimination.”
Since March 2013, when bulletin B-4.49 was released, Kattari says transgender patients can no longer be denied care or asked to pay more for it than everyone else.
“Testosterone, for example, was covered for a cis man. But a person who is female to male would go to a doctor for a testosterone prescription and get denied. That’s blatant discrimination,” said Kattari.
Though Colorado is one of just seven states with similar protections for transgender patients, it’s one of 27 states, plus Washington D.C., to expand Medicaid.
Kattari noted that the expansion has lead to an 8 percent jump in the number of transgender Coloradans with health care through Medicaid since 2011.
“That’s a huge jump,” Kattari said. “But income disparity is part of why a lot of folks now qualify for Medicaid.”
Indeed while the new One Colorado report indicates that the overall number of transgender Coloradans with healthcare has jumped from 73 percent to 86 percent since 2011, far fewer of them receive benefits through their employer than cis Coloradans. In fact, transgender people are more than twice as likely to rely on Medicaid, in large part due to astonishing income and employment gaps:
As a result, though coverage has improved, transgender Coloradans are still uninsured at higher rates than the general population (14 percent to 11 percent) and 40 percent still say cost is their primary barrier to accessing care.
Perhaps unsurprisingly, given the history of structural exclusion in health care, just under a third of transgender Coloradans say fear of discrimination is the second-biggest barrier to their accessing care. Kattari notes that discrimination against transgender people is hardly limited to the doctor’s office but extends into the everyday, from navigating social norms surrounding gender presentation and public bathroom use to being routinely addressed with the wrong pronoun. The net effect of exclusion from care and often daily discrimination paints a troubling picture of mental health for those in Colorado’s transgender community.
“These high levels of depression and anxiety are not because folks are transgender, but because of repeated experiences of prejudice and stigma,” said Kattari. “It’s hard to find a doctor who knows to ask for your preferred name and pronoun or is willing to prescribe hormones. To get access to a provider you trust is hard.”
One Colorado did find that having an inclusive provider was a serious indicator of better mental health among transgender people, though it didn’t bring patients mental health totally in line with the general population. For example, transgender people with an inclusive provider were half as likely to have attempted suicide in the past year, but still seven times more likely to have attempted than the general population.
“Until the medical community understands who transgender people are and has studied the data on the health disparities they face, transgender Coloradans’ health care needs will never truly be addressed,” Kattari concluded in the report’s release. “We have worked hard to begin tackling the barriers that transgender Coloradans face in our health systems, but there is much more work to do to ensure that all of us are receiving the care and the coverage we deserve.”
[Graphics from the Transparent report. Lead photo by Ted Eytan]