Letter from Ohio — From the February 2018 issue

Within Reach

The transgender community fights for health care

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On a balmy day last spring, Connor Chase sat on a red couch in the waiting room of a medical clinic in Columbus, Ohio, and watched the traffic on the street. His bleached-blond hair fell into his eyes as he scrolled through his phone to distract himself. Waiting to see Mimi Rivard, a nurse practitioner, was making Chase nervous: it would be the first time he would tell a medical professional that he was transgender.

By the time he arrived at the Equitas Health clinic, Chase was eighteen, and had long since come to dread doctors and hospitals. As a child, he’d had asthma, migraines, two surgeries for a tumor that had caused deafness in one ear, and gangrene from an infected bug bite. Doctors had always assumed he was a girl. After puberty, Chase said, he avoided looking in the mirror because his chest and hips “didn’t feel like my body.” He liked it when strangers saw him as male, but his voice was high-pitched, so he rarely spoke in public. Then, when Chase was fourteen, he watched a video on YouTube in which a twentysomething trans man described taking testosterone to lower his voice and appear more masculine. Suddenly, Chase had an explanation for how he felt — and what he wanted.

Illustration by Taylor Callery

This was a comfort, but he was terrified his father, an abusive man who often taunted Chase for being “butch” and overweight, would find out that he was trans. Then Chase’s dad was diagnosed with cancer, and after months on and off life support, he died in September 2016.

Afterward, Chase felt safe enough to start transitioning. He moved in with a friend who shared his love for Korean pop music and superhero movies, and took a minimum-wage job at a supermarket deli counter. He also made plans to enroll at the Ohio State University, in Columbus, and applied for Medicaid. But he’d heard that for some trans people, getting approval for hormones or surgery required many expensive sessions with a therapist, and that sometimes they were denied treatment. “I was afraid that would happen to me,” Chase said.

At the clinic, by eleven o’clock, a medical assistant led Chase into an exam room. A few minutes later, Rivard, a petite woman in her fifties with curly brown hair and a stud in her nose, came in and introduced herself. “What are you here for today?” she asked in a soft voice, her usual tone with new patients.

Chase wiped his damp palms on his jeans. He felt a rush of anxiety and excitement as he told Rivard that he was trans and wanted his friends and family to see him as male.

“What are you hoping for and how do you want me to help you?”

Chase wanted a prescription for testosterone. “I’ve done so much research, watched so many videos, and read so many articles,” he said. “I can’t think of any other solution to the way I feel.”

In the past, someone like Chase — broke, trans, and living in Ohio — had almost no chance of medically transitioning. Even if he had the money for private insurance, he might be rejected on the grounds that being trans was considered a preexisting condition. And if he found a plan that would cover him, it would probably have an exclusion for hormone replacement therapy (HRT) and other transition-related medical care, so he would have to pay out of pocket. He would also have to pay for counseling sessions so that a therapist would recommend he be prescribed hormones. Last but not least, he would have to find a doctor willing to treat him — no small task in the heart of the Midwest.

This changed when the Affordable Care Act passed in 2010, making it illegal for insurers to reject people with preexisting conditions. The law helped many trans people get coverage for the first time. According to the Center for American Progress, the proportion of trans people with incomes below 400 percent of the federal poverty level who did not have insurance has dropped by half. (There are an estimated 1.4 million transgender people in the United States, and they are twice as likely as the general population to live in poverty.) The ACA also allowed states to expand Medicaid to people earning less than 133 percent of the poverty level. In Ohio, more than 700,000 people gained coverage, including Chase.

Now, eight years since the law passed, trans people are at risk of losing much of what they’ve gained. After campaigning to repeal the ACA, Donald Trump — helped by Congress, the Department of Health and Human Services, and the Department of Justice — has spearheaded an attack. The government is also using the absence of any explicit federal nondiscrimination protection for LGBT people to undermine their civil rights and their access to health care. This has been especially significant in Ohio, which has no state-level protections for trans people and, before the ACA, offered Medicaid only to parents, pregnant women, children, and people with disabilities. Ohio also lacks the well-funded LGBT networks that exist on the coasts, so when it comes to health care, patients are particularly vulnerable to the whims of Washington. “After the election, people were trying to accelerate transition, to do everything they could, to get as much taken care of before this administration got too far in and everything started to unravel,” said Melissa Alexander, a cochair of the board of TransOhio, a prominent local advocacy organization.

The state legislature is now working to limit access to Medicaid, leaving patients, clinics, and insurers in limbo. The Columbus trans community is preparing for the worst. One woman who takes medications for depression and anxiety in addition to hormones said that if she lost coverage, she would buy what she needed online. “I’d have to be my own pharmacist,” she said. For Will Varnum, a thirty-four-year-old who began taking testosterone in 2016, fear of losing coverage meant scheduling chest reconstruction surgery as soon as possible. “In case insurance coverage goes away, I want to do it now,” he said.

Many of the services Equitas provides are supported by the ACA. Founded in 1984 as the AIDS Resource Center Ohio (ARC), the organization expanded its focus to the broader LGBT community in 2016. The Columbus clinic is one of fifteen facilities located in eleven cities across the state; it serves around four hundred trans people. Mimi Rivard sees a new trans patient nearly every day. One third are on Medicaid, and some have no insurance at all. Advocates worry that if the law changes, the most vulnerable patients — people who are poor, non-white, sick, unemployed, or living without family or community support — will be hit hardest.

Trans people already have some of the worst health outcomes in the country, thanks in part to more than a century of medical gatekeeping and discrimination. In order to address this issue, providers like Equitas have embraced a progressive approach that challenges dominant beliefs about gender and health care. In 2016, federal policy bolstered these efforts. But today, the government is intent on undermining the access to affordable and affirming care that trans people have finally secured.

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