LGBTQ HEALTH COVERAGE IN MAINE

Introduction and Summary of Findings Consumers for Affordable Health Care (CAHC) and Maine Transgender Network (MTN) partnered on a project in 2016 to investigate barriers to care and coverage for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) Mainers. We conducted three listening sessions with LGBTQ participants focused on transgender individuals, and supplemented this with a review of the design and formularies of individual market plans available in Maine.

LGBTQ individuals face many unique challenges, and thus their access to coverage and care merits serious consideration. For example, LGBTQ consumers are more likely to smoke, experience higher rates of substance use, have higher rates of mental health needs, and. are more likely to rate their own health as “poor.” They also face many barriers to getting appropriate care. This population experiences higher rates of uninsurance or underinsurance than the general population, and are more likely to face discrimination in a health care or health coverage setting.1 One statistic stands starkly above all others: 40% of trans people have attempted suicide.2 We embarked upon this project in order to better understand the experiences of LGBTQ individuals in Maine when it comes to their access to coverage and care.

Our findings include the following:

• In 2016, no individual market plan available through the Federally Facilitated Marketplace (FFM) included full coverage for transition-related services; Community Health Options (CHO) plans covered hormones but not surgery. Aetna’s off-Marketplace individual market plans did offer trans-related coverage in 2016.

o In 2017, all plans have removed trans exclusions from their plan language, but some plans continue to include language regarding trans care that may limit access to services.

• Some classes of drugs of particular concern for LGBTQ individuals, particularly those related to HIV/AIDS, are priced in ways that indicate adverse tiering and possible discrimination. These drugs also frequently include non-pricing barriers such as complex prior authorization processes, step therapy requirements, quantity limits, and the requirement that members use mail order pharmacies. This is true for both 2016 and 2017 plans.

• Our listening session participants told us that their insurance plans frequently placed unnecessary and restrictive burdens on them that led them to either seek or pay for care without attempting to access it through their insurance plan, or forego necessary care altogether.

1 http://www.lgbthealtheducation.org/wp-content/uploads/Improving-the-Health-of-LGBT-People.pdf 2 http://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF

• Both CHO and Anthem continue to place all drugs used in the treatment of HIV/AIDS on their highest plan tiers, an indication of adverse tiering.

• While all plan formularies include commonly prescribed hormone therapies, we do not have data on how easily trans individuals are able to access those drugs. Listening Session Findings Our listening sessions took place in Portland, Lewiston, and Bangor and included 20 participants. 18 of the participants identified as transgender, and most indicated that they further identified as non-heterosexual.

These sessions revealed a general acceptance by our participants that insurance would not cover anything related to an individual’s transgender status, and a common practice of seeking care and coverage outside of what many would consider to be the standard health system channels.

For instance, one participant noted that after repeated attempts to get their insurance to cover higher- gauge needles for their testosterone injections, and ongoing difficulty getting a pharmacy to stock the proper gauge, they prefer to order their needles from an online veterinary supply company.

Many participants also felt that their carriers placed undue burdens on them – for instance, long waiting periods before covering services related to their transition or trans status (e.g. demonstrating that they had “lived as” their gender identity for months or even years before authorizing services).

Many participants cited difficulty in finding trained or trans-competent providers in network near where they live. Many had switched providers or continued to travel significant distances for care from endocrinologists or mental/behavioral health providers, which was particularly burdensome when many participants reported that they had to “doctor shop” for providers with any experience or competency in providing, or even willingness to provide, care to trans individuals. Several participants noted that they spent a great deal of time educating their provider about trans issues and developing a relationship of trust. Others noted that their provider had engaged in a great deal of research and education on how to provide trans-appropriate care after they became patients. Participants cited access to mental health services in particular as a frequent concern.

Recommendations for Maine Policy Makers On December 31 2016, one day before many of the nondiscrimination protections of section 1557 of the ACA were set to take effect, a federal judge issued a temporary injunction on the rules as a result of a court challenge.6 In addition, as of the time this report is being written (January of 2017), the ACA is once more being debated at the federal level. While the future of the ACA is unclear, we expect it could undergo many changes. Our findings, however, did not change with either the injunction or the threat of ACA repeal. If anything, the uncertainty and confusion that many of our listening group participants reported to us may, in fact, increase as a result of these developments. Maine’s LGBTQ consumers are still faced with significant barriers to receiving the care and coverage they need and deserve.

6 https://www.washingtonpost.com/news/post-politics/wp/2016/12/31/federal-judge-issues-injunction-against- obama-administration-abortion-transgender-regulations/?utm_term=.7d58b5b2221d

We recommend that policy makers in Maine consider implementing strong nondiscrimination protections in state law that mirror those adopted by the ACA under the 1557 rules: specifically, that no person in Maine may be discriminated against in the delivery of health care or health coverage on the basis of their gender identity, that health care providers and insurers must treat individuals in a manner consistent with their gender identity, and that the State create a process by which individuals who experience such discrimination may report it so that corrective action can be taken if such discrimination has been found to have occurred. We would further recommend that, given Maine’s longstanding commitment to equal rights for all individuals, including strong citizen support for nondiscrimination legislation at the ballot several times over the years, our state exceed the ACA 1557 rules and prohibit discrimination based on sexual orientation as well as gender identity.