AHCA Changes Could Hurt Trans Coverage — And I'm Scared

by s.e. smith
Scott Olson/Getty Images News/Getty Images

On Thursday night, members of Congress meet to vote on the American Health Care Act, the Republicans' answer to the Affordable Care Act. Their version of health care reform would slash funding to vital services, cut key provisions of the Affordable Care Act, and encourage a net transfer of resources to the wealthy. So obviously, as an American who needs health care, I am a little worried, especially since I sit at the intersection of several identities targeted by the GOP.

While being transgender isn't a medical condition, for the purposes of accessing medical and surgical transition services, we kind of have to treat it like one. That means that my disability-related American Health Care Act (AHCA) anxiety has been amplified by my trans-related anxiety, as in: "Will I continue to be able to access services if this law passes, assuming my insurer doesn't boot me for being disabled?"

It turns out that I'm not alone in this anxiety— after the election, there was a surge across the trans community as people scrambled to get things like updating their identification and getting clearance for surgery taken care of in advance of the inauguration. Legitimately so: With a loose cannon in the White House and Republicans relishing their hegemonic control, it wasn't unreasonable to think that things might change, possibly quickly.

Certainly the administration has made it clear that it's bent on making war on the relatively small trans community — though the New York Times reports that there are only about 1.4 million of us, we evidently pose an existential threat to the security of the cis lifestyle. As if Vice President Mike Pence's anti LGBTQ record wasn't bad enough, the administration went after access provisions for transgender youth, which cover not just restrooms but a variety of gender-segregated spaces and activities. (We know you're obsessed with where we pee, but we also like to play school sports, thanks.)

Going to the clinic these days is an awkward exercise in staring around at each other nervously, trying to ignore the Republican elephant in the room: Where will we all be in a year?

So you might understand why we're a little nervous about our health care. Many of us need hormone replacement therapy and will for the rest of our lives. Some of us also require surgeries that can cost tens of thousands of dollars when paid out of pocket, making key aspects of transition financially inaccessible. The prospect of not having insurance to help with those expenses is a bit nerve-wracking.

It shouldn't be this way. In fact, the Obama Administration issued clarifying guidance for providers receiving government funding such as Medicaid, making it clear that the Affordable Care Act was designed to protect access to transgender care. Despite the clear intent of the law, insurers can and do discriminate against us on the basis of gender identity, which is why there's a slew of crowdfunding campaigns for what should be a basic right.

Going to the clinic these days is an awkward exercise in staring around at each other nervously, trying to ignore the Republican elephant in the room: Where will we all be in a year?

In California, literal bastion of San Francisco values, some of these fears feel a little more remote. My insurance provider even put out little notes telling us they're on our side, and the staff at the transitions clinic are quick to allay concerns about changes to our policies, stressing that they intend to maintain continuity of coverage. Even they fray around the edges when pressed, though, with comments that open with: "If you're worried about losing coverage..."

But, state by state, access to care is already highly variable, and conservative states may feel emboldened to change the rules, making it easier for insurance companies to decide they don't want to cover transgender care, and for health care providers to turn us down — for religious reasons, you see. Many of the arguments against providing transgender care are old news to people working in the reproductive justice movement, where health care providers insist that providing necessary health care is a restriction upon their religious freedom.

I worry for my siblings across America in states where public officials aren't making it explicitly clear that protecting them is a civic imperative, and may in fact do the opposite. I worry for those on insurance plans who aren't taking the time to proactively reach out to members to allay their concerns about the possibility of losing all or part of their coverage, particularly those with surgery dates scheduled who are anxiously waiting for their lives to change, only to see yet another hurdle on the horizon.

All we want is to be free to be ourselves, and I fear that in the coming years, I'll be contributing to a lot of crowdfunding campaigns — and attending a lot of funerals — driven by the GOP's deep-seated hatred for us.

And I worry for the direction of the AHCA, which already threatens to make it functionally impossible to access private insurance that covers abortion, in what feels like an ominous first step. The anti-abortion exclusions in the AHCA are going to hit rural communities especially hard, where many rely on hospitals or clinics that may provide abortion services with siloed funding, but will now be ineligible for government funding of any form.

But the provisions creating a powerful disincentive to include abortion coverage in any health plans are also troubling, because they establish a precedent. Why not do the same thing with transgender care and call it a cost savings that will "protect religious freedom," even though adding trans care to insurance comes at very low cost because there are so few of us, and to my knowledge my existence doesn't set Bibles aflame or refute the teachings of Christ?

Making transition services even harder to access is infuriating, especially when it comes with rhetoric about personal freedoms and the need for people to be able to choose health care plans that suit their needs. The GOP is infringing upon my personal freedom when it tells me that I can't buy insurance that covers abortion care if I want to be eligible for tax credits, and it's effectively telling insurance providers how to run their businesses this way as well — so much for small government.

Similar attacks on transgender care feel almost inevitable, because the GOP responds to things it doesn't understand and therefore loathes by trying to regulate them out of existence. There's a bitterness in the fact that the party boasting that it wants to protect liberty and deregulate our lives is about to make my life much more difficult by regulating my very existence into a corner.

We have clear, demonstrable evidence that not being able to access transition services is harmful, exacerbating mental distress and contributing to substance abuse and suicide attempts. All we want is to be free to be ourselves, and I fear that in the coming years, I'll be contributing to a lot of crowdfunding campaigns — and attending a lot of funerals — driven by the GOP's deep-seated hatred for us.

I urge people to contact their representatives about the AHCA. It's a bad bill from almost every imaginable perspective, one that will do irreparable damage to the disability community, older adults, rural communities, low-income people, and those who need reproductive health services. But I also ask you to contact your representatives because buried deep into the bones of this proposal is the notion that people who are not like you are wrong and bad, something to be eliminated. The bitter gains the trans community have clawed out in the last eight years are evaporating before our eyes.