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Hawaii is taking a small step to prevent anti-transgender discrimination in health insurance

Transgender Hawaiians may soon have to deal with one less form of discrimination in health care.

On Tuesday, the legislature passed a bill that prohibits insurers from denying, canceling, or limiting people's coverage based on their gender identity. The bill now just needs Gov. David Ige's signature to become law.

Why is the bill important? The Associated Press reported:

People in Hawaii have been denied coverage for essential medical checks like mammograms or screenings for prostate cancer because of the gender on their driver's license, said Kaleo Ramos, a transgender teacher. Ramos hopes the bill will expand access to hormone treatments.

"We're talking about people's existence, their lives," Ramos said. "This is necessary to their living, because we have so many trans deaths just because they cannot access hormones, or they can't afford hormones."

But Hawaii's bill wouldn't mandate the coverage of gender-affirming surgeries — it only applies to services already provided by health insurance plans. That may keep a big aspect of trans-related care out of reach for patients, since insurance companies could under state law still refuse to pay for gender-affirming treatments that they don't cover for non-trans patients.

Hawaii isn't alone; insurance companies can deny such care to trans people under most states' laws. Only 10 states explicitly ban trans exclusions in both private insurance and Medicaid coverage, according to the National Center for Transgender Equality (NCTE). For some trans people, this can leave a crucial aspect of their health care inaccessible.

Trans people face a lot of discrimination in health care

State laws for transgender health insurance. National Center for Transgender Equality

Trans people generally have less access to health care. Surveys show trans individuals often face verbal harassment, physical assault, and denial of care at doctors' offices and hospitals. Trans and gender-nonconforming people are also less likely to be insured — reporting an uninsured rate of 19 percent, compared with the national rate of 15 percent, at the time of the 2010 National Transgender Discrimination Survey Report on Health and Health Care.

At the same time, obtaining transition-related care is not merely a cosmetic issue; it can be a serious medical issue. Some trans people suffer from severe gender dysphoria, a state of emotional distress caused by how gender designated at birth conflicts with gender identity. This condition, the American Medical Association noted in a 2008 resolution, can lead to "distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death."

The lack of access to treatment and consequences of untreated gender dysphoria help explain one of the most haunting trans issues: A 2014 study by the Williams Institute and American Foundation for Suicide Prevention found that 46 percent of trans men and 42 percent of trans women have attempted suicide at some point in their lives, compared with 4.6 percent of the general population.

States can take steps to mitigate problems in health care by, for instance, mandating the coverage of trans-related care in private insurance and Medicaid. And other state and federal laws, such as Obamacare, may already protect trans people, although not quite as explicitly.

But without the explicit protections, states can create a great deal of uncertainty — even though trans-inclusive care isn't even expensive for major health plans.

Providing trans-inclusive care isn't very expensive

The cost of health plans doesn't increase much, if at all, if the plans include transgender-inclusive health benefits.

The Human Rights Campaign, an LGBTQ advocacy group, estimates that trans-specific treatments can cost between $25,000 and $75,000, which is minimal compared with other health care needs. And very few patients require these treatments, since trans people make up less than 1 percent of the population, making the cost relatively small for major health care providers.

Offering treatments can also save health insurers money in other areas, since trans people who receive care are less likely to struggle with mental health issues that can arise from untreated gender dysphoria.

When San Francisco began to offer trans-inclusive health coverage to its employees in 2001, the city applied a small surcharge to all employees enrolled in its health plan. But the city ended up using just $386,000 of the $5.6 million raised by the policy — a cost so low that it eventually dropped the additional charge altogether.

"[D]espite actuarial fears of over-utilization and a potentially expensive benefit," San Francisco's Human Rights Commission noted, "the Transgender Health Benefit Program has proven to be appropriately accessed and undeniably more affordable than other, often routinely covered, procedures."

San Francisco's experience shows that health plans, many of which don't provide fully trans-inclusive care, can adopt these benefits at a minimal cost. For LGBTQ advocates, getting this point across is crucial as they lobby federal, state, and local lawmakers to stop discrimination against trans people in health care plans — since, for a lot of trans people, an insurer's exclusion can be the biggest obstacle to dealing with severe, even life-threatening gender dysphoria.

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