On Thursday, Secretary Tom Price's Department of Health and Human Services issued new rules it says will strengthen the Affordable Care Act.
But if the secretary's past remarks are any indication, his tenure will likely be a disaster for the nearly 1.5 million transgender Americans who need access to lifesaving medical care. That's because Price wants to dissolve the two pillars of the unprecedented surge in transgender health care availability: Medicaid and the ACA.
Prior to his swearing-in, Price was chairman of the House Budget Committee. In 2016, he submitted a plan to slash Medicaid by $1 trillion over 10 years, leaving — according to the Center for Budget and Policy Priorities — up to 20 million people without insurance. During his confirmation hearing, Price doubled down on his pledge to "repeal and replace" the ACA.
The demise of Medicaid and the ACA "would be devastating" for transgender Americans, said Harper Jean Tobin, director of policy at the National Center for Transgender Equality.
"Trans people could see a real reversal in all the progress made over the past several years," Harper said.
That’s because the ACA did two things to broaden the availability of health care for transgender Americans. The first is the ACA requires equal access for trans and gender nonconforming individuals — in other words, those who buy private insurance through the program's exchanges or seek care in hospitals or clinics cannot be discriminated against based upon gender identity. Before the ACA, equality for transgender and gender nonconforming Americans had never been part of any federal health care program.
The second key element is that, for the 31 states and the District of Columbia participating in the ACA's Medicaid expansion, the law changed the program's income eligibility so that more poor and working poor Americans could have health care coverage. In these areas, individuals earning $17,000 a year or less can access Medicaid. This is how a majority of people have gained coverage under the ACA.
Because Medicaid provides health insurance for people in poverty — the majority of whom work, but don’t earn enough to live — it's essential for transgender and gender nonconforming Americans. According to the 2015 Transgender Survey, trans and gender nonconforming individuals face unemployment at rates up to three times higher than the general population; they're also twice as likely to live in poverty. Economic marginalization is fueled by workplace discrimination, still legal in 30 states, as well as lower levels of educational achievement due to bullying and harassment.
"Medicaid is central to transgender health care," said D'hana Perry, transgender health care coordinator at Callen-Lorde Community Health Center, which provides health care and related services to New York LGBT communities.
Depending on where a trans person lives, the integrity of Medicaid is even more vital. Since 2013, 13 states and the District of Columbia have mandated equal access to health care for Medicaid recipients regardless of gender identity, mirroring the ACA requirement. Because Medicaid is partly funded by the states, governors and state legislators get to make up many of their own rules for the program — including the ability to guarantee equality for transgender and gender nonconforming individuals. It's had a big impact: Medicaid transgender-parity requirements are on the books in states where nearly two out of five trans and gender nonconforming people now live.
The sum total of these ACA and Medicaid changes has revolutionized trans health care. An example is Callen-Lorde, the state's the largest dedicated LGBTQ health care agency. After New York allowed Medicaid to provide transgender-specific health care services, the number of transgender and gender nonconforming patients treated by Callen-Lorde increased by almost 25% in just one year.
"When I started at Callen-Lorde in 2013, there were very, very few patients accessing transgender surgeries," Perry said. "But once the state law changed, all of a sudden, even more patients sought care. When the rules changed it gave people something to live for."
Indeed, the ability to access mental health services essential to receiving hormones and gender-confirming surgeries has been liberating like never before.
"Having a body which matches who you are is a life-changing moment," Perry said.
More than half of transgender and gender nonconforming people who were not able to access essential care have attempted suicide.
We know access to health care is a matter of life and death for trans people.
According to The Williams Institute, more than half of transgender and gender nonconforming individuals attempted suicide after being unable to access essential care. But the transgender and gender nonconforming community faces additional health care challenges. For instance, nearly six out of 10 black transgender women are HIV-positive.
"Increased access ... has led to reduced morbidity, mortality and HIV transmission," noted Dr. Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation. "A loss of access could reverse these trends."
That’s why Price’s drive to axe Medicaid and the ACA is such a threat. It puts some of the most under-resourced Americans with critical health care needs on the federal budget’s chopping block.
The good news is the transgender and gender nonconforming community is increasingly mobilizing against the emerging threat. This mobilization, combined with the fact that Price needs 60 Senate votes to enact many of his proposed changes, just might be enough to save the recent transformation of the American health care system.