Trans People in the Health Reform Fight: What's at Stake

The news is breaking that the Senate will vote this month on a bill to advance "Trumpcare" and repeal key sections of the Affordable Care Act (ACA). The ACA has helped more than 20 million people obtain new health insurance coverage, including trans people, people living with HIV and millions of others who were previously locked out of coverage. It bans coverage denials because of pre-existing conditions; requires insurance plans to cover important care such as HIV tests, prescription drugs and mental health services; and prohibits discrimination against LGBT people's access to coverage and care. In contrast, Trumpcare, or the American Health Care Act (AHCA), is bad news for trans people -- particularly those living with or at risk for HIV. Here's why, and here's what we can do about it:

Loss of Health Insurance Coverage

According to the nonpartisan Congressional Budget Office, the AHCA would cause 23 million Americans to lose their health insurance coverage by 2026. Trans people are already more likely than cisgender people to not have health coverage, and trans women, in particular, have among the highest rates of HIV. The ACA has been making progress in closing the coverage gap -- and the AHCA would undermine that progress in four main ways.

  1. Ending Medicaid as we know it. Thirty-one states and the District of Columbia have expanded their Medicaid programs under the ACA, making Medicaid coverage available to everyone with incomes up about $18,500 per year (133% of the federal poverty level). Medicaid expansion has increased coverage for people living with HIV, and 12 states have changed their rules in the last several years to cover gender transition-related care. The AHCA would end Medicaid expansion and convert Medicaid to a block grant program, in which states would receive a fixed amount of federal funding for their Medicaid programs, regardless of how many people actually need Medicaid coverage.
  2. Slashing tax credits that help pay premium costs. The ACA created tax credits that operate on a sliding scale -- the lower your income, the greater your tax credit -- to help make health coverage more affordable. The AHCA would replace these credits with credits that start off smaller to begin with, especially if you're over age 55, and don't increase when your income goes down. Health economists have calculated that by 2020 the average tax credit recipient would pay $2,409 more under the AHCA than under the ACA, people aged 55-64 would pay $6,971 more and people with incomes under about $35,000 per year (250% of the Federal Poverty Level) would pay $4,061 more.
  3. Eliminating cost-sharing subsidies. The ACA provides subsidies that reduce out-of-pocket insurance costs for people making less than 250% of the federal poverty level. The AHCA would eliminate these subsidies.
  4. Open season on "pre-existing conditions" -- including gender transition. Under the ACA, insurance carriers cannot deny coverage or increase premiums based on pre-existing conditions such as HIV or even a history of gender transition. The AHCA, though a provision known as the MacArthur Amendment, would allow states to waive these protections.
4 in 10 low-income LGBT people are on Medicaid
Center for American Progress (CAP)

Inadequate Coverage

The ACA improved the quality of health insurance coverage by ending three common insurance practices that particularly harmed people who regularly need health care due to conditions such as HIV: plans that paid for only a small amount of actual health costs, plans that excluded important health care services from coverage and "high-risk pools." The AHCA would reintroduce all these practices.

  1. Eliminating actuarial value standards. The ACA created four levels of insurance plans -- bronze, silver, gold, and platinum -- that represent percentages of cost-sharing, meaning the average percentage of an enrollee's medical costs that the plan will cover: for example, a bronze plan covers 60% of costs, and a platinum plan covers 90%. The AHCA would eliminate the actuarial value standard.
  2. Undermining the essential health benefits. The ACA created a set of "essential health benefits (EHB)" that most plans must cover. The EHB include hospital care, doctor visits, prescription drugs, lab tests, mental and behavioral health care, preventive screenings and other critical services. Under the AHCA's MacArthur Amendment, states could waive the EHB requirement.
  3. Segregating people with HIV and other "high risks" into separate risk pools. Before the ACA, people with pre-existing conditions were often sequestered into separate risk pools, for which premiums were exorbitant and coverage severely limited. High-risk pools have all but disappeared as the ACA's reforms have taken effect. Under the pretense of cushioning the blow from the reintroduction of barriers to coverage for people with pre-existing conditions, the AHCA would allot $8 billion to fund state-based high-risk pools. The problem? Eight billion dollars comes nowhere close to meeting the cost of covering everyone who would end up in these pools: In fact, it represents less than 1% of what the AHCA would cut from programs that currently help people afford coverage.
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Center for American Progress (CAP)

Weakened Nondiscrimination Protections

In addition to financial help to afford coverage, the expansion of Medicaid and new standards for plan quality, the ACA introduced new protections that prohibit discrimination against LGBT people, people living with HIV and others who have historically been mistreated when seeking health coverage and care. The law's primary nondiscrimination protection, Section 1557, would not be repealed by the AHCA in its current form. However, Secretary of Health and Human Services Tom Price and President Trump have already promised to join forces with Congress to continue the work of dismantling the ACA from the inside. The passage of the AHCA would give the Trump administration exactly the ammunition it needs to destroy the remaining parts of the ACA -- including the law's nondiscrimination protections.

What to Do About It

Trans people, people living with HIV and millions of our friends and allies are in danger from the American Health Care Act. The passage of the AHCA would undo seven years of progress on making health insurance coverage and health care fairer, more affordable and more accessible. Here's how to show the Senate that we can't afford to go back:

  1. Check out these resources: Indivisible has a wealth of resources on the opposition to Trumpcare.
  2. Make your voice heard: Use this line set up by SEIU: 866-426-2631 (English) or 877-736-7831 (Spanish) to call the Senate and tell your Senators that you oppose Trumpcare because it hurts our families, our communities and us.

Kellan Baker, M.P.H., M.A., is a senior fellow with the LGBT Research and Communications Project at the Center for American Progress, where he works on a range of LGBT health policy issues. Baker is a founding steering committee member of Out2Enroll, a nationwide initiative that works to connect LGBT people and their families with new health insurance coverage options under the Affordable Care Act.