Starting today, open enrollment for the Affordable Care Act (ACA) will set in motion a trifecta of change. The ACA adds protections for many, expands coverage for services once considered rare, and ensures the vast majority of the population will receive affordable preventive care. With Black folks more likely to die from cancer, and higher rates of diabetes and heart disease, the preventive care made available in the ACA is crucial, but as gains are made for some, adequate health care is still a distant dream for many of the most vulnerable and misunderstood among us. Whether trying to get a basic doctor’s visit, mental health services, or HIV/AIDS related care, Black trans* people have an uphill and often dangerous battle.
The ACA deals with technical issues that have prevented many trans* individuals from obtaining insurance. It prevents insurance companies from turning away trans* health care seekers, dropping current clients from coverage because of their gender identity, and canceling trans* clients’ insurance due to paperwork mistakes, including misgendering a client or using a former name. This is great news, but for many, insurance is unaffordable and competent care is not available due to bias and inexperience.
Even when covered by a major health insurance company in the San Francisco Bay Area—the epicenter of cutting-edge trans* healthcare—it was difficult for Kelly Lewis to find competent care. "The doctor told me he didn’t feel comfortable prescribing shots, so he wanted to start me on the patches," Lewis was told by a doctor when seeking testosterone hormones. “I felt that this physician was more of a gatekeeper than a provider,” he continued. After requesting to change doctors, Lewis was asked by the office to stay because the doctor wanted to learn about transgender healthcare—on his body. While the provider’s intent to learn more about trans* health care appeared noble, no one should have to be treated as an experiment especially given the sordid history of experimentation on Black bodies in this country. The lack of education among providers and the ongoing stigma facing Black trans* people factor prominently in health disparities in the Black trans* community—the ACA does not specifically address healthcare discrimination based on gender identity or expression,** which is a prevalent experience.
Before care is possible, simply affording insurance remains an issue. Thirty-four percent of Black trans* people earn less than $10,000 per year making co-payments, insurance premiums, and other healthcare costs not covered by the ACA out of reach. Nineteen percent of the Black and trans* communities under 65 are uninsured while a 2010 trans* discrimination survey found that 31% of Black trans* people were uninsured. While lack of health insurance is not the only factor in the health disparities these communities face, it is a major one.
Although more people will be accessing healthcare through state health exchanges and Medicaid expansion, the ACA does not address healthcare discrimination—a prevalent experience among trans* people. Twenty-one percent of Black trans* people have been refused medical care due to transphobic bias. A 2011 report found that 34% of respondents avoided seeking health care because they feared discrimination. But discrimination is not only relegated to blatant anti-trans* bias from providers and staff, it also exists in the medical community’s minimal knowledge and sensitivity around trans* issues. As Lewis experienced in seeking a knowledgeable provider, few medical staff have access to the necessary professional training to expand their scope of gender and their provider skillset. More accessible and knowledgeable training would allow the providers to serve a client based on the varied bodies of transwomen, transmen, and gender nonconforming people and their whole being—not just their body parts.
Going beyond body parts is crucial when considering mental health care, which remains a delicate and important issue within the Black community. The ACA guarantees that mental health and substance abuse services are required coverage in plans under the Essential Health Benefits Categories. The Obama Administration’s 2014 budget bolsters this by setting aside $205 million to increase access to mental health programs that address the high rates of suicide. While this is a positive step, many in the trans* community still may not get the care they desperately need. The trans* community as a whole attempts suicide at a rate of forty-one percent and nearly half of those are attempted by Black trans* individuals. While services may be offered to all, the stigma around accessing such services combined with the general lack of access to qualified providers will still leave many in the trans* community without support, and vulnerable to transphobic violence.
Receiving sub-par health care is so widespread it begs the question: “Why have insurance at all?” The answer is complicated. Without adequate training, more trans* community members will remain underserved. The ACA has made great strides in making healthcare more accessible and affordable to the uninsured and underinsured, but still upholds barriers for a great number of trans* people. In working towards a more inclusive healthcare system, let’s work together to change the Affordable Care Act—to the Accessible and Competent Care Act.
Note: Trans* is an umbrella term meant to encompass identities within the transgender and gender nonconforming spectrum, including, but not limited to transgender, genderqueer, transmen, transwomen, Two-Spirit, masculine of center, androgynous, gender fluid, and bigender.
**ETA: While the Affordable Care Act does not specifically address discrimination based on gender identity or expression, it does prohibit discrimination based on sex in all health care settings receiving federal funds. Patients who experience discrimination can file a complaint with the Department of Health and Human Services and the claims will be investigated to ensure that everyone receives respectful medical care.
Kelly Eusaint Lewis is a trans* social justice and political organizer based in Oakland, California. He has worked on statewide legislation supporting trans* and gender nonconforming youth of color and has served as a mentor for masculine of center and transmen through the Brown Boi Project.
Renee Bracey Sherman is a freelance writer, reproductive justice activist She is a member of Echoing Ida, a collective of Black women writers organized by Strong Families, and a graduate student at Cornell University. Follow her on Twitter at @rbraceysherman