Policy Memo: Insurance Non-Discrimination Gender Identity

To: Referred to Senate Committee

From: Aja Elmore

Subject: Insurance Non-Discrimination Based on Gender Identity Date: 11/17/16

House Bill 2084
Introduction
Actions at the federal level to discourage discrimination have had little impact on the
reality for many transgender patients. The nondiscrimination clause of the Affordable Care Act
(ACA) of 2010 is not enough to protect transgender patients from denial of insurance coverage
(Gillespie, 2015). Despite federal efforts to end discrimination, states still have the authority to
determine what constitutes as discrimination. HB 2084 seeks to prohibit insurance companies
from denying and discriminating against people based on actual gender or perceived gender
identity in the state of Hawaii (HI HB 2084, 2016).
A study by the National Transgender Discrimination Survey in 2011 revealed that 19
percent of surveyed individuals reported being refused medical care because of their gender, 28%
postponed care due to discrimination, and 37% postponed medical care due to inability to afford
it. Half of respondents reported having to explain transgender issues to their providers. These
practices have contributed to negative health outcomes for transgender people when compared
with the general public including elevated rates of depression, suicide, substance abuse, and HIV
(Grant, Mottet, & Tanis, 2011). Multiple studies highlighting transgender discrimination have
been published, including a 2013 study by the Virginia Transgender Health Initiative which
states that 41% of polled participants reported experiencing transgender-related discrimination
(Bradford, Reisner, Honnold, & Xavier, 2013).
Opponents to HB 2084 argue that passing the bill will increase insurance rates as
insurance companies will be forced to pay for elective transition surgeries. Mara Keisling,
founder and director of the National Center for Transgender Equality states that discrimination
goes beyond transition surgery. Insurance companies refuse transgender men and women sexspecific preventative care such as pap smears and prostate exams. What happens is that the
health insurance companies have specific codes and they put you in as female or male; you only
get services that go with that code, said Robin Maril, senior legislative counsel at the Human
Rights Campaign, an advocacy group for lesbian, bisexual, gay and transgender people
(Gillespie, 2015). Rules proposed by HB 2084 will force insurers to cover necessary preventative

Policy Memo: Insurance Non-Discrimination Gender Identity

services, regardless of gender listed in patient history.
Background
Transgender people are excluded from many insurance policies and programs which
limits the health care treatment that these individuals can receive. HB 2084 seeks to prohibit the
denial, exclusion, or limitation of health care to a person based on a persons actual gender or
perceived gender identity (HI HB 2084, 2016). The National Transgender Discrimination
Survey: Report on Health and Health Care released nationally by the National Gay and Lesbian
Task Force and the National Center for Transgender Equality revealed widespread discrimination
in health care environments (Grant et al., 2011).
Key findings from the study include:

Survey participants reported very high levels of postponing medical care when sick or

injured due to discrimination (28%)

Survey participants reported being refused care due to their transgender or gender non-

conforming status, with even higher numbers among people of color in the survey (19%)
Harassment: 28% of respondents were subjected to harassment in medical settings and

2% were victims of violence in doctors offices

A significant number of study participants postponed necessary medical care due to
inability to afford it, whether seeking care when sick or injured (48%), or pursuing

preventive care (50%)

Those who have private insurance were much less likely to postpone care because of
inability to afford it when sick or injured (37%) than those with public (46%) or no

insurance who postponed care (86%).

Respondents reported over four times the national average of HIV infection, 2.64% in our
sample compared to .6% in the general population, with rates for transgender women at
3.76%, and with those who are unemployed (4.67%) or who have engaged in sex work

(15.32%) even higher

41% of respondents reported attempting suicide compared to 1.6% of the general
population

Possible Policy Solutions

Timely and equal access to health care is the primary recommendation of a study by
Daphna Strousma, MD, MPH whose work was published in the American Journal of Public
Health (Strousma, 2014).

Policy Memo: Insurance Non-Discrimination Gender Identity

The Affordable Care Act (ACA) includes gender identity into its nondiscrimination
clause, however, the extent to which it will protect transgender individuals from denial of

insurance coverage on a state level has yet to be seen.

Establish more health centers dedicated to caring for transgender patients as well as

strengthen those already in operation.

Clear guidelines for all federally funded health centers, including appropriate language,
adoption of gender-neutral bathrooms and health records that respect transgender

patients preferred names and gender pronouns.

Include questions regarding gender identity in health surveys to help monitor the

progress and effects of new transgender health care measures.

Transgender-sensitive care must be incorporated into medical, nursing, and paramedical
curricula, as has been done with other cultural competencies.

Recommended Solutions
The current state of affairs allows insurance companies to deny necessary health care
services to transgender people. This impacts access to necessary health care and leads to
traumatic and profoundly negative health outcomes for this population.
I want to advocate for the passage of HB 2084 which will allow transgender patients
equal access to health care regardless of actual gender and perceived gender. Additionally, I
would propose funding for educational programs teaching medical care of transgender patients.
To create equal access to health care for transgender patients, I would recommend establishing
more health care centers dedicated to the care of this demographic and allocate more funds to
support the centers that are already operational.

References

Policy Memo: Insurance Non-Discrimination Gender Identity

Bradford, J., Reisner, S. L., Honnold, J. A., Xavier, J. (2013). Experiences of transgender-related
discrimination and implications for health: results from the Virginia Transgender Health
Initiative Study. American Journal of Public Health, 103 (10). doi:
10.2105/AJPH.2012.300796
Gillespie, L. (2015). Transgender people still denied health services despite affordable care act.
PBS News Hour. Retrieved from http://www.pbs.org/newshour/rundown/transgenderpeople-still-denied-health-services-despite-affordable-care-act/
Grant, J. M., Mottet, L. A., Tanis, J. (2011). National transgender discrimination survey report
on health and healthcare. National Gay and Lesbian Take Force. Retrieved from
http://www.thetaskforce.org/static_html/downloads/resources_and_tools/ntds_report_on_
health.pdf
HI HB2084 | 2016 | Regular Session. (2016, June 30). LegiScan. Retrieved November

18,

2016, from https://legiscan.com/HI/bill/HB2084/2016

Strousma, D. (2014). The state of transgender health care: Policy, law, and medical frameworks.
American Journal of Public Health, 104 (3). doi: 10.2105/AJPH.2013.301789