Category Archives: Trans-Inclusive Healthcare

Questions for USOPM Director of Diversity and Inclusion Regarding Trans-Exclusionary Federal Insurance Policies

Today, the Department of Transportation Office of Civil Rights announced its 2015 DOT Civil Rights Virtual Symposium. The Symposium includes the following program:

“Dear OPM: I have a problem, what do I do?”
Veronica Villalobos, Director, Office of Diversity and Inclusion, Office of Personnel Management
This “Dear OPM” session will feature a column style conversation addressing guidance on inclusion efforts in the Federal workplace such as transgender policies, religious accommodation, pregnancy, disability, among others.

I have attempted to correspond with Ms. Villalobos and her office several times in an effort to get an answer on the trans-exclusionary health insurance policies offered to Federal employees by OPM. So far, OPM has steadfastly refused to say anything more.

As an attendee of the program I was given the opportunity to ask a question.

Veronica Villalobos
Director
Office of Diversity and Inclusion
U.S. Office of Personnel Management
veronica.villalobos@opm.gov

Dear Ms. Villalobos:

Before I ask my question, I’d like to thank your office for the 2011 guidance on gender identity issues that may arise in the workplace, particularly when an employee transitions at work. I know that the guidance has helped many trans people; I know it helped me when there were some individuals who didn’t understand that, as a woman, I would be using the women’s restroom at work. As the Department of Labor considers how to implement Executive Order 13672, prohibiting discrimination on the basis of sexual orientation and gender identity by Federal contractors, they should look to OPM’s leadership on the issue.

My question comes to that leadership, and where it has unfortunately been lacking. In June 2014, after many delays and a nontrivial amount of litigation, OPM finally made a minor update to its policy on gender identity with respect to health insurance. In FEHB Program Carrier Letter 2014-17, OPM claimed to “remove the requirement” that all FEHB brochures exclude “services, drugs, or supplies related to sex transformations” categorically, regardless of medical necessity. Instead, carriers would now have “one of two options” – covering this care without discriminating on the basis of gender identity, or maintaining the general exclusion and denying medically necessary care on the basis of gender identity.

If you’ll forgive a brief aside, it’s worth noting here that OPM later admitted in a FOIA response that there was no such requirement on record. One year prior, in plan year 2014, one health insurance carrier, Kaiser in California, offered trans-inclusive health insurance, despite the purported requirement, with full knowledge and consent of OPM. There was no requirement – there was a practice, a practice OPM’s carrier letter permitted to continue.

Digression aside: OPM’s minor update to its policy on gender identity and health insurance led to only a minor change. Of the 304 FEHB plans, 15 (or less than 5%) eliminated the discriminatory provision. Under current OPM policy, the other 289 health insurance carriers (including the single carrier insuring over 63% of Federal employees) may continue to exclude care solely because it is a “service, drug, or supply related to sex transformations.” That means that even if a service is covered, if it is related to a “sex transformation” (i.e. medical transition, described using grossly offensive language), a carrier may exclude it. Under FEHB regulations, OPM accepts legal responsibility for each of these health insurance plans.

The Department of Justice is filing briefs stating that discrimination on the basis of gender identity is discrimination on the basis of sex. Under the 2012 EEOC decision Macy v. Holder, such discrimination is illegal. Under Title VII, such discrimination is illegal. Under Executive Order 13672, such discrimination is illegal.

Here is my question:

Can we hope that the Office of Personnel Management will prohibit trans-exclusionary health insurance policies in plan year 2016?

Until then, why does the Office of Personnel Management continue to tolerate discrimination on the basis of gender identity within the express terms of the contracts it makes with health insurance plans?

When the Office of Personnel Management’s Office of Diversity and Inclusion updated its regulations on nondiscrimination provisions, why did it choose to ignore its FEHB contracts?

Why has your own office failed to respond to these issues when brought to your attention, such as the letter I sent your office on December 9 and January 15, or the work of any number of organizations advocating for transgender equality, or amidst a quiet but steady stream of litigation on this issue?

When will the Office of Personnel Management show leadership and ban trans-exclusionary health insurance policies, so that the Department of Labor and the Department of Health and Human Services can enforce the Affordable Care Act’s prohibition on discrimination on the basis of gender identity for all Americans?

Quite simply, the effort to ban health insurance contracts that discriminate on the basis of gender identity cannot succeed through Federal action until the Federal government ends its own discrimination against transgender Federal employees. Until your office acts, the Department of Labor and the Department of Health and Human Services are hamstrung in any efforts they may make to eliminate such discrimination – after all, the Federal government permits the discrimination for its own employees.

Sincerely,

— Emily T. Prince, Esq.

New Letter to OPM: Failure to Timely Respond to Petition for Trans-Inclusive Health Insurance for Federal Employees

UPDATE: Ms. Wong is, as of October 2014, on the Board of Governors for the Human Rights Campaign. That would seem to be a conflict, since HRC is theoretically opposed to Ms. Wong’s activities at OPM. At OPM, she is responsible for a recent nondiscrimination rule that failed to address ongoing and persistent illegal discrimination by OPM against transgender Federal employees.

Sharon Wong
Deputy Director for Coordination and Policy
Office of Diversity and Inclusion
Office of Personnel Management

Transmitted via email

Ms. Wong,

I’m not sure what cause there is for the delay in response to my Petition for Reconsideration, filed with your office on August 25, 2014. While I’ve been unable to find OPM’s rules of practice for Petitions for Reconsideration, I do know that my employing agency handles them much quicker by rule. 49 CFR §211.31 provides a period of four months for responses to Petitions for Reconsideration, and that is for an agency that regularly promulgates technically complicated rules with net societal benefits in the billions of dollars.

It has been over four months since my Petition was filed. OPM’s failure to respond to my Petition in a timely fashion is demonstrative of OPM’s general failure to treat transgender Federal employees with respect. This lack of respect is exemplified by the June 13, 2014 FEHBP carrier letter 2014-17 in which OPM acknowledged that transition-related care is medically necessary but nonetheless, in defiance of Macy v. Holder, continues to allow insurers to discriminate on the basis of transition in their offerings of health insurance coverage. This lack of respect was further demonstrated on November 24, 2014, when OPM answered a question about the matter during a Google Hangout on Federal benefits by simply reiterating the contents of the offending letter.

I continue to look forward to a substantive response from your office, as well as looking forward to the day when I am not discriminated on the basis of my gender identity as a Federal employee.

Sincerely,
— Emily T. Prince, Esq.

cc: Kamala Vasagam, General Counsel, Office of Personnel Management

Letter to FDA: Decision of Blood Products Advisory Committee Regarding “MSM” Ban

UPDATE (December 23, 2014 4:00 pm): I contacted the FDA to inquire again about the policy, since I continue to see it referred to as a ban on “men who have sex with other men” and was told that the office was “reluctant” to issue a response prior to announcing today’s potential policy shift, even though my question doesn’t relate to the change from lifetime deferral to one-year celibacy period.

Lorrie H. McNeill
Director
Office of Communication, Outreach and Development
Center for Biologics Evaluation and Research
Food and Drug Administration
10903 New Hampshire Avenue
Building 71 Room 4120
Silver Spring, MD 20993-0002

Transmitted via e-mail

Re: Decision of Blood Products Advisory Committee Regarding “MSM” Ban

Dear Ms. McNeill,

I was disappointed to hear of the recent decision by the FDA’s Blood Products Advisory Committee to remain silent on the question of whether to eliminate the ban on blood donation from “men who have sex with other men at any time since 1977,” sometimes referred to as the “MSM” ban. However, when I contacted your office for more information I was horrified to hear confirmed that the FDA, to this very day, considers sex assignment at birth both immutable and internet, such that transgender women and other individuals assigned male at birth are perpetually considered “men” for the purposes of the ban.

This fact underscores the arbitrary and capricious nature of the “MSM” ban. Rather than looking at actual risk factors, the FDA has concluded that if a person born with (probably) a penis and assigned male at birth, the fact of that person’s sexual interaction with another person born with (probably) a penis and assigned male at birth renders both individuals categorically tainted and ineligible to donate blood. The set of people affected by the “MSM” ban includes the following pairs:

a cisgender heterosexual man who has a sexual relationship with a transgender heterosexual woman;
a transgender homosexual woman who has a sexual relationship with another transgender homosexual woman;
a transgender bisexual woman who has a sexual relationship with a genderqueer person assigned male at birth; and
a genderqueer person assigned male at birth who has a sexual relationship with a cisgender bisexual man.

This policy creates significant harm to transgender people and people with non-binary gender identities, for instance by reifying the false belief that transgender women are “actually men.” This incorrect understanding of what it means to be transgender underlies so much discrimination against transgender people. In a month where the Department of Labor has finally begun the hard work of eliminating discrimination on the basis of sexual orientation and gender identity among Federal contractors, the FDA’s Blood Products Advisory Committee’s decision is particularly frustrating.

When the full reach of the “MSM” ban is stated, the purported basis for the ban falls away. The policy can include cisgender men of any sexual orientation, transgender women of any sexual orientation, and anyone with a non-binary gender identity who was assigned male at birth who has sexual relationships with anyone else assigned male at birth. Yet the FDA, in defiance of its own acknowledged interpretations, continues to refer to it as a ban on donations by “men who have sex with men” and defends it against salient attacks by the American Red Cross, the American Association of Blood Banks, America’s Blood Centers, the American Medical Association, and patient groups such as the National Hemophilia Foundation. In response to the sound science presented by these organizations, the FDA responds with flawed statistics about “men who have sex with men” without even acknowledging the full set of people impacted by the ban.

Were the FDA to attempt to defend its actual policy, rather than the straw-man it has created, it would be forced to admit that sex assignment at birth does not meaningfully impact the risk of contracting HIV, and that there are too many confounding variables in the total population affected to justify categorically prohibiting all donations from that population for life.

I look forward to hearing from your office regarding how the FDA will improve its rules regarding blood donations in the future to eliminate this arbitrary and capricious ban.

Sincerely,

Emily T. Prince, Esq.

cc:
Jocelyn Samuels, Director, Office of Civil Rights, U.S. Department of Health and Human Services

Letter to Department of Labor: Request for Administration Position on Trans-Exclusionary Insurance Contracts

Ms. Debra A. Carr
Director, Division of Policy and Program Development
Office of Federal Contract Compliance Programs
Department of Labor

Transmitted via e-mail

Dear Ms. Carr:

Thank you for your hard work to complete the regulations required by Executive Order 13,672, prohibiting discrimination on the basis of sexual orientation and gender identity by Federal contractors. However, in the Department’s haste to publish the regulation after years of review, many unanswered questions remain. I would welcome the opportunity to work with your office to address these questions. This letter pertains to a particularly pervasive and toxic form of discrimination on the basis of gender identity: insurance contracts that, despite generally applicable coverage, deny coverage for claims that relate to being transgender.

In the attached audio file, CareFirst BlueCross BlueShield, a Federal contractor, admits that their policies deny coverage on the basis of gender identity. Presumably, discrimination of such a direct and overt form must be prohibited by the new rules, but when I contacted your office for an opinion on a similar fact pattern, I was told that the Office of Federal Contact Compliance Programs had no legal opinion on the matter. This was somewhat surprising, since the matter was discussed with OFCCP several weeks prior through the Office of Information and Regulatory Affairs.

While the recorded conversation pertained to plans available under the Federal health insurance exchanges, CareFirst Blue Cross, like 95% of FEHB insurance carriers providing insurance services under contract with the Federal government, states in their plan language that they categorically exclude “services, drugs, or supplies related to sex transformation.” According to the Office of Personnel Management in its FEHB Program Carrier Letter 2014-17, issued June 13, 2014, such exclusions are entirely legal, even when performed by the Federal government itself.

Similarly, the Department of Health and Human Services Office of Civil Rights previously stated for over a year and as recently as August 2, 2013 that such discrimination was permissible under 42 USC §18116, though declined to provide the basis upon which it reached that determination. The statement was subsequently removed from the Department of Health and Human Services website before the end of August 2013 without comment. While a Request for Information was published in August 1, 2013 and many commenters addressed the insidiousness of this form of discrimination, the Department of Health and Human Services has yet to react to the information submitted. In the Fall 2014 Unified Agenda, the Department of Health and Human Services announced that it would not be publishing even a proposed rule on the topic until April 2015, over 5 years after the passage of the statute to be interpreted.

This dramatic discrepancy between the rhetoric of the Administration and the implementation of policy raises the question: will the Administration continue to tolerate discrimination on the basis of gender identity in the context of health insurance? If so, upon what basis does the Department of Labor conclude that a Federal contractor stating directly that they are intentionally discriminating on the basis of gender identity is not a violation of Executive Order 13,672, Title VII of the Civil Rights Act, and other prohibitions against discrimination on the basis of sex, including discrimination on the basis of gender identity? If the Administration does not intend to tolerate this discrimination, how much longer must the transgender community wait for action?

Similarly, does the Office of Diversity and Inclusion in the Office of Personnel Management or the Office of Civil Rights in the Department of Health and Human Services have any response?

Sincerely,
— Emily T. Prince, Esq
http://www.emily-esque.com

cc:
Jocelyn Samuels, Director, Office of Civil Rights, Department of Health and Human Services
Veronica Villalobos, Director, Office of Diversity and Inclusion, Office of Personnel Management

Attachment:

Despite Delay, in New Antidiscrimination Rule Labor Leaves Much “Under Review.”

On Friday, the Department of Labor formally published rules implementing this summer’s Executive Order prohibiting Federal contractors from discrimination on the basis of gender identity and sexual orientation. The rule is cause for some measure of celebration: as the Obama Administration moves into its seventh year in office, it is starting to take steps to fight the endemic levels of employment discrimination faced by the LGBT community. However, for transgender and non-binary people, the actual impact of the rule remains to be seen. Despite years of waiting for the Department of Labor to enforce existing protections against discrimination on the basis of gender identity, the Department still lacks answers to fundamental questions of how the rules will be applied. Obvious issues the Department failed to address include:

how employers should handle transition of employees;
the interaction with the existing prohibition on discrimination on the basis of sex (including gender identity); and
conditions of employment such as employer-provided trans-exclusionary health insurance and gender-specific dress codes.

According to the Williams Institute, 42% of lesbian, gay, and bisexual people have been discriminated against in the workplace on the basis of their sexual orientation. Even this high number is dwarfed by the 78% of transgender people who have experienced harassment, mistreatment and discrimination in the workplace on the basis of gender identity. A 2012 estimate calculated that the rules would provide additional protection to approximately 11 million people on the basis of sexual orientation and 16.5 million more people on the basis of gender identity.

No guidance has been provided on how to avoid discriminatory actions when an employee transitions at work, despite the fact that the Department could have relied upon the “gender identity guidance” published by the Office of Personnel Management in 2011. Adverse employment actions, such as firing, demotion, or a failure to hire, solely on the basis of gender identity are clearly prohibited by the new rules, though the Equal Employment Opportunity Commission held such discrimination was discrimination on the basis of sex over two years ago in Macy v. Holder. The Department lacks an explanation of how the new rules interact with its much-delayed guidance from August 19, 2014 on Macy’s application to existing Federal contracts.

Unfortunately, the rules also do not provide any clarity on discrimination in conditions of employment, despite well-known problems to be addressed. Perhaps most pervasively, many employers (including the Federal government itself) exclude claims related to being transgender or non-binary from their insurance policies. When asked if the Department had an opinion on the legality of such exclusions, the Department’s Office of Federal Contract Compliance Programs Division of Policy stated they had no opinion on the matter, despite having plenty of warning that advocates were going to want an answer. Given that the Federal government still, with few exceptions, has these exclusions in the health plans available to its own employees, the Department’s reticence is perhaps understandable. It is nonetheless disappointing, given that inability to access medically necessary care related to transition is associated with a 10 to 15 percentage point increase in the likelihood of lifetime suicide attempts by transgender and non-binary people, already plagued by a horrific lifetime suicide attempt rate of 41%.

The importance of increasing access to transition-related care should not detract from the host of other important issues that the rules fail to address. Due to what may be a drafting error by the Department, the existing prohibition on sex-segregated facilities except with respect to “restrooms and necessary dressing or sleeping areas” has been rendered ambiguous. Unfortunately, advocates against nondiscrimination rules for gender identity often turn restrooms into battlegrounds. Because the Department failed to provide an explanation of how contractors are expected to “assure privacy between the sexes” without discriminating on the basis of gender identity, advocates against the rule may decide to file a lawsuit on the matter, claiming that the rule actually prohibits people from using restrooms consistent with their sex and gender identity.

The rule similarly fails to address workplace dress codes. This is likely to create problems for businesses with gender-specific dress codes, as people whose gender identity is not congruent with either “male” or “female” will not fit neatly into such categories, and the rule prohibits discrimination on the basis of gender identity, including non-binary gender identity. Guidance here would be particularly useful, but because the rule fails to address it, it will fall to the people the rule is intended to protect to educate both the Department and Federal contractors. Previous attempts asking the Administration to allow for non-binary official documentation have failed to even generate a response acknowledging the existence of non-binary people, let alone policy outcomes that take non-binary people into account.

With a scope reaching tens of millions of employees of Federal contractors, it is possible that Friday’s rule signifies a marked change in the protections available to LGBT people in the workplace. However, until the Department of Labor is ready to explain how the rule applies to the many varied ways employers have developed to discriminate on the basis of gender identity, transgender and non-binary people are once again left waiting for answers that may never come.

Update: in July of 2013, Department of Labor published its own guidance on avoiding discrimination on the basis of gender identity (as a type of discrimination on the basis of sex) in the workplace, consistent with OPM’s guidance. It is unclear why they could not provide this same guidance to Federal contractors. The guidance has substantial flaws, but it would nonetheless be better than no answer at all.

New Department of Labor “LGBT” Rule Published; Labor Lacks Answers on Transgender Exclusions in Health Insurance

Today, the Department of Labor announced publication of its final rule implementing Executive Order 13,672 of July 21, 2014, which required the Department to publish rules prohibiting Federal contractors from discriminating on the basis of sexual orientation or gender identity (an additional press release is available). The rule further reinforces existing law and supplements the EEOC’s decision in Macy v. Holder: discrimination on the basis of sexual orientation and gender identity is illegal.

Since the rule failed to address health insurance, I called the Department of Labor’s Office of Federal Contract Compliance Programs. After a transfer, I wanted to make sure I was speaking with the right people.

Emily: I’m not actually sure which department I’m speaking with.

OFCCP: I’m in the national office at OFCCP, in the policy division. We’re pretty much it.

I asked the OFCCP compliance officer:

Emily: If a insurance provider is, or rather, if an employer is providing insurance that discriminates on one of the protected bases, would that be prohibited by this regulation.

[some conversation ensues about who the proper person to answer that question would be; the OFCCP compliance officer eventually puts me on hold to see if there is a prepared answer]:

OFCCP: Emily?

Emily: Yes.

OFCCP: OK, I’m so sorry to keep you on hold for so long.

Emily: Totally understandable.

OFCCP: But I wanted to clarify, you know, to make sure, and basically the only thing we can say at the moment that it applies the same way our other rules apply in terms of how, essentially, terms and conditions of employment apply.

Emily: Right.

OFCCP: And that includes benefits such as health insurance.

Emily: Right. But the Department of Labor is not willing at this time to state that it is legal, or… let me back up, state that it is discriminatory or not discriminatory to deny a claim solely on the basis that a person is transgender?

OFCCP: As I say, if it’s the same benefit, it ties to the same sort of benefit with health insurance.

Emily: Right, but Department of Labor does not have a definitive legal opinion on that question.

OFCCP: No.

[additional conversation occurs about how to obtain an agency statement of policy on that question]:

Emily: I absolutely understand if it’s the case that you don’t have an opinion yet.

OFCCP: Exactly. The rule hasn’t even been published yet; it won’t be published until Friday.

[more conversation occurs about contacting the individual named in the rule, when the compliance officer states]:

OFCCP: Unfortunately, at the moment all we can say is just basics of-

Emily: Yup.

OFCCP: If it’s an employment benefit and it’s offered to everybody else and applies to everybody else it has to apply the same way here. That’s the short answer.

Here’s a fact pattern: what would Department of Labor say about CareFirst (a Federal contractor) and its insurance policies (including the policies for Federal employees)?

CareFirst: Commonwealth of Virginia, OK: for transgender surgery, it’s not going to be covered.

[discussion of hormone replacement therapy, leading to time on hold]

CareFirst: Hormone replacement therapy?

Emily: Yes ma’am.

CareFirst: It’s not going to be… hormone replacement therapy, it doesn’t look like that’s going to be covered either. Anything that’s related to that transgender, it’s not going to be covered.

I plan to ask the Department of Labor that very question. It will be interesting to hear their response.

OPM Continues to Have Nothing New to Say about Anti-Trans Discrimination

Since June 13, 2014, it has been the explicit policy of the U.S. government to discriminate on the basis of gender identity with respect to health insurance.

I have attempted since that date to get the Administration to rectify this discrimination. It has failed to do so.

In a November 24 discussion of Federal benefits, the Office of Personnel Management chose to address the question squarely:

https://twitter.com/emily_esque/status/536863422621962240

Here’s the offending language:

You might notice that the woman called on to respond is reading the June 13 letter that was referenced in my question, which she clearly had at the ready to read, verbatim, as an answer to the question. This is what OPM considers “responsiveness.”

The gentleman hosting that call was Alan P. Spielman, Assistant Director for Federal Employee Insurance Operations in OPM’s Healthcare and Insurance Program Division. Sometime that same day, November 24, 2014, Mr. Spielman signed the response to my FOIA request of July 29, 2014. Again, this is what OPM considers “responsiveness.”

In that FOIA response, OPM provides a complete list of plans that do not discriminate on the basis of gender identity. There are 304 FEHB plans.

That’s 15. 15 plans out of 304, or less than 5%, do NOT discriminate on the basis of Gender Identity.

Under current OPM policy, the other 289 health insurance carriers may continue to exclude care solely because it is a “service, drug, or supply related to sex transformations.” That means that even if a service is covered, if it is related to a “sex transformation” (i.e. transition, described using the most offensive language possible), a carrier may exclude it. Under FEHB regulations, OPM accepts legal responsibility for each of these health insurance plans.

Under Macy v. Holder, such discrimination is illegal. Under Title VII, such discrimination is illegal. Under the President’s Executive Order of July 21, 2014 (EO 13,672) such discrimination is illegal.

The Office of Personnel Management clearly does not care.

Thanks to Amélie E. Koran for compiling information on the total number of plans and their general lack of trans-inclusiveness.

Meeting Notes: OIRA Discussion on Federal Contractor Nondiscrimination Rule

The OIRA meeting record and handout are now available.

On Thursday, Kristin Beck, Mia Macy, and I met with officials from the Office of Information and Regulatory Affairs (OIRA), the White House Counsel’s office, the Domestic Policy Counsel, the Department of Health and Human Services (HHS), and the Department of Labor (Labor). The meeting concerned the implementation of the much-heralded July 21, 2014 Executive Order prohibiting discrimination on the basis of gender identity in Federal employment and prohibiting Federal contractors from discriminating on the basis of sexual orientation or gender identity. On October 20, 2014, Labor submitted their draft regulations implementing the Executive Order to the White House for approval prior to publication as a “final rule,” meaning there would be no opportunity for the public to comment. Kristin, Mia, and I took the opportunity to explain to the Administration that trans-exclusionary health plans are illegal, their elimination would be substantially beneficial for society, and would accomplish one of the Administration’s key policy aims. There is literally no legitimate basis for the Administration to fail to act to prohibit trans-exclusionary insurance policies offered by Federal contractors.

Unfortunately, the Administration has given transgender advocates plenty of cause for concern with the new regulation. In June of 2014, the Office of Personnel Management issued a letter to insurers participating in the Federal Employees Health Benefit Program, noting that transition-related care is medically necessary but nonetheless allowing insurers to discriminate against such care simply because it is for the benefit of trans people. Similarly, HHS’s first attempt to interpret the nondiscrimination provisions within the Affordable Care Act (ACA) rejected out of hand the idea that it required coverage of transition related care. The timing of the Executive Order itself also gave rise to concerns. For two years, reporters had been asking Labor for information on how it was enforcing an Equal Employment Opportunity Commission (EEOC) decision holding that discrimination on the basis of transition was discrimination on the basis of sex; the Administration response was to prohibit the most dogged reporter from public events in order to dodge questions.

Because there will likely not be an opportunity for public comment on the draft regulation, it was all the more important to make the case to the Administration through OIRA that it should prohibit transition-related care exclusions in Federal contractor health insurance plans. The arguments we presented ran along three themes: prohibiting trans-exclusionary health insurance plans is legally required; such a prohibition would deliver massive net societal benefits; and it’s in the publicly-articulated interests of the Administration. While I focused largely on the technocratic details, both Kristin and Mia did an absolutely phenomenal job in emphasizing the human element at play with these exclusions.

The legal case is blessedly simple. There is no real debate that transition-related care is medically necessary; the Administration has already admitted as much in the June 2014 OPM Carrier Letter, stating “there is an evolving professional consensus that treatment is considered medically necessary for certain individuals who meet established Diagnostic and Statistical Manual criteria for a diagnosis of Gender Identity Disorder / Gender Dysphoria.” The professional consensus is further demonstrated by the host of professional medical organizations issuing resolutions to that effect. In Macy v. Holder, the aforementioned EEOC decision (in which Mia Macy was the plaintiff), the EEOC clearly stated that discrimination against the act of transitioning was itself discrimination on the basis of sex. The trans-exclusionary language of health insurance plans clearly falls into this category. The language from Federal employee health insurance contracts is styled as prohibiting coverage for “services, drugs, or supplies related to sex transformations.” Other insurance plans are even more obvious, and have exclusions for “all services related to gender dysphoria or gender identity disorder.” Such exclusions are de jure discrimination against transition-related care; regardless of what other coverage is available, if the procedure to be covered is for the purpose of transition, the insurer refuses coverage. In addition to the Macy decision, there is also the nondiscrimination language of the Administration’s hallmark achievement, the ACA. 42 U.S.C. §18116, also referred to as §1557 of the ACA, prohibits discrimination on the basis of sex (including gender identity) in health programs or activities, including health insurance. As trans-exclusionary clauses in health insurance are discrimination on the basis of gender identity and therefore also discrimination on the basis of sex, they are illegal and the Administration should have no qualms about requiring Federal contractors to get rid of such clauses.

There are two sides to the economic case for removing trans-exclusionary insurance clauses. First, the actual costs of removing the clauses are negligible; second, the benefits of removing the clauses are high, due to the significant benefits that accrue to trans people becoming able to receive health insurance.

There is quite a bit of data to support the fact that removing exclusions for transition-related care poses no significant costs. When San Francisco broke new ground in implementing its coverage for transition-related care, the deal was struck in such a fashion that insurers were permitted to charge additional costs on top of general premiums in order to account for the benefit. While the additional costs charged initially were on the order of $1.70 per enrollee, insurers quickly discovered that this was a vast miscalculation. Despite having every interest in demonstrating high costs of covering transition-related care in order to justify maintaining the additional premium costs, insurers were unable to do so. Within several years of San Francisco’s removal of transgender exclusions, insurers could no longer justify any additional cost for covering transition-related care. When California evaluated its statewide mandate for trans-inclusionary health insurance policies, the state’s Department of Insurance issued an Economic Impact Assessment finding that “the aggregate cost to the state population as a whole will be very insignificant.” The Williams Institute found similar results when analyzing 34 employers who had implemented trans-inclusive health insurance policies. 85% of the sample reported no costs associated with the change in policy (such as an increase in premiums).

While the costs of providing trans-inclusive health insurance is low, due in large part to the low number of trans people in the general population, the costs of denying such coverage are high on an individual basis. The American Medical Association resolved that delays in treatment from financial barriers “can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illnesses, depression, and substance abuse problems.” Lack of access to transition-related care, combined with other economic discrimination against transgender people, pushes transgender people towards survival sex work to fund medically necessary care. Furthermore, the Williams Institute and the American Foundation for Suicide Prevention found an astounding prevalence of suicide attempts among the transgender community, 41%, vastly exceeding the national average of 4.6%. Inability to access medical care increased the likelihood of a suicide attempt by between 10 and 15 percentage points. If one must, as OIRA does, assign a numeric value to human life, the dramatic consequences for inability to access care lead one to the conclusion that the benefits far exceed the negligible costs. In terms of Federal benefit/cost analysis, the net societal benefits for such a policy will easily exceed $100 million, if not $1 billion. Numbers on that order of magnitude would normally all but compel the White House to act to achieve such benefits.

The White House has also made clear that inclusion of transgender people is a policy goal about which it would at least like to speak. The Administration frequently declares that discrimination on the basis of gender identity should be illegal, arguing that one shouldn’t be discriminated against at work because of “who you are.” Trans-exclusionary health policies are a particularly pernicious form of that kind of discrimination; it effectively bars transgender people from certain jobs or certain employers, or significantly reduces the amount they are paid purely because they are transgender.

Furthermore, the White House has declared that it will act where it has the power to do so and where Congress refuses to do so; that declaration led to the issuance of Executive Order 13,672, which required these regulations. Requiring Federal contractors to eliminate transition-related exclusions from their health insurance policies is entirely within the power of the Executive Branch, and Congress has refused time and again to pass the Employment Non-Discrimination Act as a way to deal with the issue.

Finally: the Administration is justifiably proud of the Affordable Care Act and how it has extended access to health insurance to millions of Americans. President Obama has been heard to proudly boast of eliminating discrimination based on gender and pre-existing conditions, and former Speaker Pelosi has often been heard to say that “being a woman is no longer a pre-existing condition.” Sadly, for transgender women, that’s simply not the case.

It is well past time for the Department of Labor to prohibit Federal Contractors from offering trans-exclusionary health insurance policies. If this regulation fails to do so, the Administration will discover that trans people will not be ignored.

Update: Also worth noting: the Human Resources Policy Association, an organization of “over 350 large and influential corporations” met with OIRA several days prior alongside IBM and Proctor & Gamble, both companies that HRC designates as having trans-inclusive health insurance, to discuss the rule. Their concerns appear to relate to potential affirmative action requirements in the Executive Order.

Meeting request to OIRA – Regulations Implementing Prohibition of Discrimination Based on Sexual Orientation and Gender Identity by Federal Contractors

Today, I filed a meeting request with the Office of Information and Regulatory Affairs concerning the direct final rule the Department of Labor sent to the White House to implement President Obama’s Executive Order 13,672 (July 21, 2014), which prohibits Federal contractors and subcontractors from discriminating on the basis of sexual orientation or gender identity.

The reason for the meeting is simple: present Obama Administration policy suggests that the Department of Labor may attempt to issue regulations which claim to prohibit such discrimination, but allow Federal contractors and subcontractors to discriminate against employees with respect to health insurance benefits through maintaining exclusions for transition-related care. As noted previously, all of the nationwide insurance plans open to all Federal employees maintain discriminatory clauses excluding transition-related care from coverage. This creates cause for concern that the Department of Labor will similarly allow such exclusions.

The draft regulations have been provided to the White House in the form of a “direct final rule,” meaning there is no opportunity for public comment prior to the regulations being published in final form. While there remain administrative remedies available after publication, it would be best if the White House gets the regulations correct in the first place and prohibits all Federal contractors and subcontractors from offering health insurance benefits that discriminate on the basis of gender identity.

Response to Continued OPM Stonewalling

I don’t normally post every back-and-forth in my attempts to shake things loose from the bureaucracy (as there are many and they are generally boring). However, it has been 68 days since I submitted a FOIA request to OPM requesting the responses to Federal Employee Health Benefits (FEHB) Program Carrier Letter 2014-17 (which announced that OPM would continue to discriminate on the basis of gender identity at the behest of insurers) in order to get a sense of how many insurers would actually be offering trans-inclusive health insurance in plan year 2015. To date, OPM has failed to respond to the FOIA request, including not even acknowledging receipt.

Since they’ve decided to stonewall, I’ve decided to escalate. First, I’ve now included the Office of Civil Rights at my employing agency, since OPM is continuing to discriminate against all transgender Federal employees, myself included.

Second, in the coming days, I will be referring the matter to my Senator, Sen. Tim Kaine, because letters from the Hill tend to actually force responses loose from Federal agencies. The letter will also address the complete lack of response OPM has had to my Petition for Reconsideration, filed back in August, to their “nondiscrimination” rule that still allows discrimination against transgender Federal employees through FEHB.

By the time I receive a response, it may well be “open season,” the period of the year when insurers plans for the next year are posted online for anyone to review any plan. However, I nonetheless hope OPM responds, as manually culling through volume after volume of plan brochures to find which are discriminating and which are not is a heap of unnecessary work given that OPM requested (and presumably received) a simple list of which insurers are which.

Emily Esque

Fighting for Justice through Bureaucratic Black Magic