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Thursday Aug 03, 2017

Start by Viewing Transgender Patients as People -- Not 'Burdens'

"Is my Pap smear covered by insurance?"

It's a question I hardly hear anymore because the Patient Protection and Affordable Care Act guarantees coverage of recommended preventive care(www.kff.org), even under private insurance plans, without patient cost-sharing.

[View of military troops from behind]

But the patient who asked this question was in a different position: he's transmale (born female, still with a cervix) and someone who has faced a lifetime of discrimination in the health care system.

He, and patients like him, have good reason to be confused and worried. On the heels of an important health care vote last week, President Donald Trump tweeted the announcement of a ban on transgender individuals in the military.

The announcement -- had it been actual policy and not just a tweet -- would have been a reversal of Obama administration policy that allowed transgender Americans to serve openly. That policy also allowed coverage of the cost of gender-confirming surgery with approval from the military.

Transgender people, Trump said, are expensive, and providing them care is a burden. The implication is that these men and women, who have dedicated their lives to protecting ours, are unworthy of that coverage.

That argument is both false and dangerous. The reality is that the cost of care for transgender persons is relatively small, between $2.4 million to $8.4 million, according to studies from the New England Journal of Medicine(www.nejm.org) and RAND Corp. That's an increase in expenditure of 0.04 to 0.13 percent of the military's annual $47.8 billion annual health care budget.

But cost should be irrelevant. Numerous medical associations, including the AAFP, agree that transition-related care is medically necessary(www.lambdalegal.org). In fact, the cost of not treating trans patients is high. Research has found that treating transgender patients is cost effective, as it leads to lower rates of substance abuse, suicide risk and improved health outcomes(www.nejm.org)

Discrimination against people with disabilities or pre-exsiting conditions is precipitated by viewing patients with dollar signs over their heads, rather than simply seeing them as people. It's particularly dangerous for transgender patients, who still face discrimination in the workplace, health care, housing and more.

In addition to getting transition-related services covered (exclusions still vary state-by-state and plan-by-plan), transgender Americans have faced another barrier to care: preventive services. In 2015, HHS told insurers that preventive care, such as Pap smears and mammograms, should be covered without copay or out-of-pocket costs based on a person's risk, regardless of a patient's gender identity (i.e., a transmale with a cervix should not face barriers to getting a Pap smear).

One of my patients told me that he didn't change his gender markers on official documents like Social Security cards and his driver's license for years because he feared losing insurance coverage for important things like mammograms and Pap smears, but that all changed when protections became guaranteed.

But now my patients are worried about rollbacks to existing policy. Did Trump's tweet signal that more discrimination against them is yet to come from their own government?

In December, a federal district judge in Texas blocked regulations intended to protect trans individuals. The current administration has rescinded prior inclusive school policies for trans students(www.nytimes.com)

The tweet was not a distraction. It was a deliberate attempt to cloak hate and discrimination behind an economic argument (one that fails).

The AAFP, for its part, has spoken out against discrimination toward transgender people. But we need a chorus of doctors, medical organization, hospitals, and patient advocacy groups to also stand with our patients.

About 4,000 people who are transgender serve in the U.S. military, based on conservative estimates -- and likely hundreds of thousands of transgender troops have served throughout our country's history. An analysis from the University of California, Los Angeles(williamsinstitute.law.ucla.edu), estimated that more than 100,000 transgender individuals are either veterans or retired from military service.

The history of transgender soldiers in the U.S. military dates at least to the Civil War, when Albert Cashier(www.washingtonpost.com) served in Company G, 95th Illinois Regiment. He didn't collect Army pension after refusing a physical exam, but his biological birth as a female was discovered late in life when he was treated by doctors following a car accident.

Americans who are transgender have long fought for our rights in the U.S. military. The least we can do is fight for theirs.

Natasha Bhuyan, MD, is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).  

Posted at 05:20PM Aug 03, 2017 by Natasha Bhuyan, M.D.

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