Even as more health centers nationwide become trained to provide LGBTQ-competent care and more insurers (public and private) cover transgender-related care such as hormones and surgeries, queer and trans folks—especially those in red states and rural areas—still often feel left out in the cold when it comes to medicine. Last year, a Center for American Progress survey found that 15% of LGBTQ Americans report postponing or avoiding medical treatment due to discrimination, including nearly three in 10 transgender individuals.
A.G. Breitenstein, J.D., M.P.H., 52, wants to change all that. She’s the genderqueer-identifying founder and CEO of Folx Health, the subscription-based health care service for queer and trans folks that launched in December, soon raising $25 million in venture funding. After graduating from Yale and then the University of Connecticut law school, she started the legal program at the Sidney Borum Jr. Health Center in Boston, which serves LGBTQ youth. “I was working with kids on the streets with high rates of HIV,” she says.
From there, she went to the Harvard School of Public Health “to figure out a better way with health care” for LGBTQ people. And from there, she says, “I became a serial entrepreneur, trying to get better [health care] data out there,” selling one of her data companies to Optum, a health care–specializing venture capital firm. That experience gave her an “understanding of what the conflicts of interest were across health care insurance infrastructure—I really saw why the health care system was broken for everyone.”
She left the world of venture capital with a vision for “a queer and trans community [oriented] direct-to-consumer virtual health platform,” which she calls “the most amazing and obvious idea, because we [LGBTQ folks] always find community in virtual space. There was Grindr before Tinder.”
Folx is the culmination of her vision. For monthly fees ranging, in her estimation, from $59 to $200 a month, LGBTQ folks in 19 states so far can sign up for plans covering estrogen or testosterone (for trans, nonbinary, and intersex customers) or erectile dysfunction, with plans “coming soon” (the website says) for HIV pre-exposure prophylaxis (PrEP), sexually transmitted infection testing kits, hair care, and skin care. The service not only mails meds and necessary paraphernalia (like syringes) monthly to subscribers in attractive and discreet packaging, with automatic refills, it also provides 24-7 virtual access to a growing team of providers, all of them appearing to be queer or trans/nonbinary and about half appearing to be Black, Indigenous, or other people of color (BIPOC).
According to Breitenstein, the average Folx prescription costs the same or less than what the average person pays yearly in deductibles and copays on a typical health plan (which Folx says is $1,644) but offers the convenience and privacy of having medications sent to your home as well as the safety of having an LGBTQ-identifying and culturally competent provider. That, says Breitenstein, can be a boon to people in, for example, rural areas with no LGBTQ-specializing or -trained health center nearby.
“The health care system shouldn’t be judging us,” says Breitenstein. “It should be serving us.” With most providers, she says, the attitude toward LGBTQ patients, “whether it’s access to HRT [hormone replacement therapy], PrEP, etc., is, ‘Prove to us you’re gonna behave, and we’ll treat you.’ That whole script has to be flipped on its head.” Folx exists, she says, to remove all those judgments and hassles.
At the same time, Folx is not a comprehensive primary care plan that includes trips to the ER or urgent care, meaning that people getting some needs met via Folx would have to get the rest of their health needs met elsewhere, via either private insurance coverage or public coverage, like Medicaid, Medicare, or the AIDS Drug Assistance Program (ADAP).
Most people with incomes low enough to be on ADAP or Medicaid likely could not afford Folx’s out-of-pocket costs, while even middle-class people paying some share of their own money for their health plans might not have more money to pay for what Folx provides. Additionally, a growing number of large and mid-size American cities now have at least one health center with at least decent LGBTQ care, even if it’s not as convenient as not having to leave the house for meds and provider visits.
All of which raises questions about how many people will sign up for Folx. Breitenstein says that subscriber growth has been “exponential week over week” since the December launch. Currently, she says, the subscriber base is in the hundreds to thousands and growing really fast. Stats show about 11 million queer and trans people in the U.S., she says, “but I think 40 million is closer to the truth. We’re a powerful and discerning customer segment.”
Folx has a charity component, too: With the nonprofit Trans Lifeline, it has set up the HRT Care Fund, which has already given a year’s worth of free hormone therapy (and related care) to 100 trans- or nonbinary-identifying people and plans to release another 24 such “microgrants” come June 1, with 75% of such grants going to BIPOC people.
Mixed Community Reaction
I set out to learn what, if anything, queer and trans people, especially experts in the health field, were saying about Folx. I first asked that question, noting it was for a news story, on the Facebook page Trans MSM: Rethinking Sexuality and Health. Among the roughly 10 people who replied, the replies were not great. One person called the company “exploitative” while another said the model seems “dubious,” offering very little care for exorbitant fees.
“Privatized health care isn’t the future of trans wellness, despite what people who pay $1,200 a year for an HRT Rx tell you,” one person wrote. And, of course, the inevitable: “I really really really hate the name Folx.”
I needed to get a more professionalized take, so I reached out to Kellan Baker, Ph.D., M.P.H., a transgender researcher at Johns Hopkins Bloomberg School of Public Health who focuses on trans people and health coverage, including private-sector health startups. He has decidedly mixed feelings. “I’m familiar with the idea that sometimes it can be easier for different types of services to be delivered in a subscription model, which has been happening outside of trans health,” says Baker. Top of mind are the men’s services Hims and Roman, which provide things like hair-loss and erectile-dysfunction meds.
Baker acknowledged Folx’s potential usefulness in some places for some people. “It’s often difficult for people to get access to gender-affirming hormone therapy—insurance carriers, physicians, and pharmacy [staff] can all still pose a problem,” he said. “Getting your refills for long-term meds like injectable testosterone is a pain. So I understand the desire to have a service where you are paying for convenience, privacy, and the ability to have some assurance that you can navigate accessing these meds without running into people who are going to mistreat you because you’re trans.”
Plus, Baker says, he understands that some people, especially in rural areas, live far from LGBTQ-competent health providers or pharmacies. Finally, he appreciates that Folx appears to be providing jobs to trans, nonbinary, and/or BIPOC health providers.
His critique comes in, he says, because “we’ve always had this challenge of people thinking that trans health care is not legitimate, that these are not medically necessary services that should be accessible only under special conditions, and this is exactly what [the Folx] model is promoting. I don’t like that hormone therapy for trans people needs to be carved off and provided under special circumstances in discreet packaging. I’m not saying that people shouldn’t have privacy, but why is [trans health care] so special? There’s an underlying message of shame.”
Then, he says, there’s the fact that services like Folx pull those who can afford them away from being part of the push to universalize LGBTQ (especially trans) coverage and meds in public and private plans and to universalize LGBTQ-competent care standards in health centers nationwide. He points out that only 22 states explicitly require Medicaid to cover trans health care, while 11 states explicitly forbid it.
“The more people with means to escape the health systems the rest of us have to deal with [to go to a private service like Folx], the worse the situation is likely to become for those left behind,” he says. “I don’t think it’s the responsibility of any given trans person to stay in a broken system in order to make it better, but this model of separate services for people who can pay is a trend that I don’t like. I’d prefer to focus on making the existing system work better for trans folks rather than set up a private escape hatch. I can afford Folx, but I’m not comfortable doing so because of what it means.”
The benefits of Folx listed by Baker were echoed by Emmet Phipps, FNP-BC, AAHIVS, a trans health provider at New York Presbyterian/Weill Cornell in New York City who specializes in fellow trans/nonbinary folks and those living with chronic illnesses including HIV. Phipps, who uses they/them pronouns, said they know two people currently working for Folx. (They haven’t been approached by Folx, they say, but did nearly take a job with Plume, a competing LGBTQ-oriented hormone therapy service.)
“Everyone involved with Folx seems extremely dedicated to having queer and trans folks get amazing health care,” says Phipps. “A program like this is incredibly important for people who can afford it. I love Folx’s message of ‘You are a beautiful person, and we want you to live.’ We [queer/trans people] often don’t get that message.”
But, continues Phipps, “on a philosophical level, I think hormones should be free, and I just wish that the $25 million they raised could go to some sort of general fund of buying hormones for people. And I wish that every trans person in the U.S. had a neighborhood health provider where they could take care of all of their needs. But we’re not anywhere near that yet as a country, so Folx is filling in a gap for some people.”