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ACLU advocates for trans Colo. man

Resident saddled with debt after insurance ruling

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transgender, caduceus, medicare, gay news, Washington Blade, health, gender reassignment
Transgender Center of Excellence, gender dysphoria, transgender, caduceus, medicare, gay news, Washington Blade, health

NEW YORK — The ACLU has asked the Colorado Civil Rights Commission to review the complaint of a man who was denied access to health care. 

Dashir Moore, a transgender man from Georgia, wanted a fresh start in life. So at the age of 31, he packed up and moved to Colorado, a state that offered both a great lifestyle and trans healthcare. He hoped he could finally be himself, the ACLU announced in a press release. 

Things went well at first. Almost immediately after Dashir arrived in Colorado, he was able to update the gender marker on his driver’s license. He got a job as a customer service rep.

Then he scheduled chest surgery. No stranger to our byzantine insurance system, Dashir called his benefits line to check if the procedure was covered and was told it would be. He also confirmed that he didn’t need prior authorization before the surgery.

But shortly after the surgery, he found out his insurance would not pay for the procedure and he soon found himself saddled with medical debt and out of a job.

Two days afterthe surgery, his care coordinator called and told him that his insurance company had refused to pay after all. Dashir learned that his employer had selected a health insurance plan that excludes medical expenses incurred for “Gender Transition: Treatment, drugs, medicine, services and supplies for, or leading to, gender transition surgery.” Dashir began to receive bills from the hospital, which eventually totaled almost $30,000. His anxiety skyrocketed and Dashir couldn’t continue to work.

Insurance carve-outs for transition-related care are illegal. But as Dashir learned the hard way, that hasn’t stopped some from continuing to deny transgender people the care they need. Here’s the truth about transition-related health care.

Myth: Transition-related care is optional.

Reality: Transition-related care is anything but optional.

Many transgender people experience gender dysphoria, the medical term for incongruence between a person’s gender identity and their sex assigned at birth where such incongruence results in clinically significant distress. Medically accepted standards of care for gender dysphoria include social transition, hormone treatment and surgery. The goal of treatment for gender dysphoria is to alleviate distress by helping patients live in accordance with their gender identity. In Dashir’s case, medically necessary care for his gender dysphoria included surgery to remove breast tissue and create a male chest.

If not addressed, gender dysphoria places patients at great risk for depression, anxiety, self-injury and suicide.  In other words, failure to treat gender dysphoria can mean the difference between life and death.

Myth: Insurers don’t have to cover transition-related care.

Reality: Insurers can’t deny patients otherwise covered services because they are part of gender transition.

Insurers can limit coverage to care that is medically necessary, but they can’t deny medically necessary care based on who a patient is. For example, the surgery Dashir needed — a mastectomy — is routinely covered by insurance companies to treat patients with cancer or a genetic predisposition to cancer, such as the BRCA genes. But Dashir was denied coverage for the same procedure because he is transgender and needed it to treat his gender dysphoria. That’s discrimination.

Myth: Coverage for transition-related care is too expensive.

Reality: Coverage for transition-related care costs just pennies per insured.

Opponents of transgender equality, including President Trump have used cost to justify denying transgender people medically necessary care, but their objections don’t stand up to scrutiny. An expert hired to defendthe state of Wisconsin’s exclusion for transition-related care recentlyestimated the cost of coverage would be between four and 10 cents per insured per month. That represents less than 0.1 percent of overall medical costs.

It’s hard to imagine Wisconsin claiming it was justified in denying medical coverage for treatment for other conditions, like depression or diabetes, to save pennies per month, yet that’s exactly what it did in denying coverage for transition-related care. That sends a deeply disturbing message about the value placed on transgender people’s lives.

Dashir may be down, but he’s not out. Together with the ACLU, he filed a charge of discrimination against his former employer to end the discriminatory denial of health care. We’re standing with Dashir and transgender people across the country so that all of us have the freedom to be who we are.

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As monkeypox spreads, Delaware looks to expand vaccine access

Those exposed to virus prioritized in limited distribution

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(Image courtesy of the U.S. Centers for Disease Control and Prevention)

The Delaware Division of Public Health on Aug. 4 confirmed the fourth, fifth, and sixth cases of monkeypox in the First State. Less than a month after the state announced its first case of the virus, the spread of monkeypox in Delaware mirrors trends across the country in what the U.S. Department of Health and Human Services has now declared a public health emergency.

Three Delawarean men ages 42, 24, and 19 were diagnosed with the most recent cases of the virus — none of whom reported close contact with an individual diagnosed with monkeypox, and all of whom are now self-isolating.

In an Aug. 4 press release, DPH noted that it intends to expand vaccine distribution, offering vaccines to high-risk groups with or without exposure to the virus.

Currently, the state only offers post-exposure prophylaxis, vaccines implemented after an individual comes into contact with a virus. Those who have had direct contact with individuals with confirmed cases of monkeypox are currently prioritized in the state’s limited post-exposure vaccination.

Groups that might be prioritized upon increased vaccine access include individuals who have had intimate contact with someone diagnosed with monkeypox within two weeks, individuals with multiple sexual partners within three weeks, individuals who have had intimate contact through dating apps, parties or clubs, and individuals who are HIV-positive or are currently receiving pre-exposure prophylaxis for HIV, according to the news release.

Some researchers suggest current monkeypox cases are underrepresented in public health statistics nationwide. Although monkeypox has been declared a national health emergency, Delaware has yet to make a similar declaration on the state level. DPH noted that health officials will continue to monitor public health conditions.

DPH encouraged Delaware residents and visitors to avoid close contact with those who have symptoms related to monkeypox, limiting their number of sexual partners, and cleaning their hands with soap and water or hand sanitizer regularly. DPH also urged those experiencing symptoms associated with monkeypox to contact their health care provider immediately, make a list of intimate contacts in the last three weeks and self-isolate until symptoms subside.

For more information, individuals can contact the DPH hotline for monkeypox-related questions and concerns on weekdays from 8:30 p.m. to 4:30 p.m. at 866-408-1899, or email  [email protected]. Information concerning monkeypox prevention programs and resources can be found at de.gov/monkeypox.

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Biden names White House National Monkeypox Response Coordinators

Governors of New York, Illinois, California declare ‘States of Emergency’

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President Joe Biden meets with his national security team on July 1. (Official White House Photo)

The White House announced Tuesday that President Biden has named FEMA’s Robert Fenton as the White House National Monkeypox Response Coordinator and Dr. Demetre Daskalakis as the White House National Monkeypox Response Deputy Coordinator.

The president’s actions come as the governors of New York, Illinois and California have declared ‘States of Emergency’ as the case numbers of global cases of infection also caused World Health Organization’s Director-General Dr. Tedros Adhanom Ghebreyesus to declare the escalating global monkeypox outbreak a Public Health Emergency of International Concern.

The White House notes that Fenton and Daskalakis will lead the Administration’s strategy and operations to combat the current monkeypox outbreak, including equitably increasing the availability of tests, vaccinations and treatments.

Both men have extensive experience in infection disease outbreaks and response. The White House statement laid out their qualifications:

Fenton and Daskalakis combined have over four decades of experience in Federal emergency response and public health leadership, including overseeing the operations and implementation of key components of the Biden Administration’s response to the COVID-19 pandemic, and leading local and Federal public health emergency efforts such as infectious disease control and HIV prevention.

Both played critical roles in making COVID vaccines more accessible for underserved communities and closing the equity gap in adult vaccination rates, through the implementation and execution of FEMA mass vaccination sites in some of the country’s most underserved communities, and working with trusted members of local communities to build vaccine confidence.

Robert Fenton currently serves as Regional Administrator for FEMA Region 9 in the American West, with nearly 50 million people in his area of responsibility. One of the Nation’s most experienced and effective emergency management leaders, Robert Fenton has twice served as Acting Administrator of FEMA and led multiple challenging prevention, response and recovery operations throughout his long and distinguished career, including for natural disasters, disease outbreaks, and complex humanitarian operations. 

Demetre Daskalakis, a leading public health expert, is currently Director of the CDC Division of HIV Prevention. Widely known as a national expert on health issues affecting the LGBGQIA+ communities, his clinical practice has focused on providing care for the underserved LGBTQIA+ communities. He previously oversaw management of infectious diseases for the New York City Department of Health and Mental Hygiene, one of the largest departments in the nation – including in serving as incident commander for the City’s COVID-19 response.

Both the U.S. Secretary of Health and Human Services and the President’s chief medical advisor issued statements applauding Biden’s actions.

“We look forward to partnering with Bob Fenton and Demetre Dasklalakis as we work to end the monkeypox outbreak in America,” said HHS Secretary Xavier Becerra. “Bob’s experience in federal and regional response coordination, and Demetre’s vast knowledge of our public health systems’ strengths and limits will be instrumental as we work to stay ahead of the virus and advance a whole-of-government response.”

“Bob Fenton and Dr. Daskalakis are proven, effective leaders that will lead a whole of government effort to implement President Biden’s comprehensive monkeypox response strategy with the urgency that this outbreak warrants,” said Dr. Anthony Fauci, Chief Medical Advisor to the President. “From Bob’s work at FEMA leading COVID-19 mass vaccination efforts and getting vaccines to underserved communities to Demetre’s extensive experience and leadership on health equity and STD and HIV prevention, this team will allow the Biden Administration to further accelerate and strengthen its monkeypox response.”

The Centers for Disease Control and Prevention as of Monday reported that there were 5,811 confirmed cases of the monkeypox virus in the United States.

Statement from GLAAD President and CEO Sarah Kate Ellis:

“The White House appointments today reflect the seriousness of the monkeypox (MPV) outbreak and should be a call for all appropriate federal and state officials to urgently commit necessary resources to educate the public and counter MPV. We must get more vaccines to vulnerable people, especially sexually active gay and bi men, and accelerate all efforts to inform the public to track, test, treat and contain this virus as quickly as possible. Bob Fenton’s experience shows this can be done. Dr. Demetre Daskalakis is a longtime LGBTQ and HIV health advocate whose work will be critical to ensure the federal government responds to the needs of the medical community and the LGBTQ community in equitable ways.”

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With time, the Monkeypox vaccine provides good protection

In clinical trials, recipients who were HIV negative had an 83 percent immune response 28 days after one dose compared to 98 percent with two doses at 42 days.

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A review of academic literature published in the Journal of Internet Medical Research last year determined, when it comes to information about health topics, social media is not the place to turn. (Unless you follow me, of course!) One study found 87 percent of health-related posts contain misinformation. More than 40 percent of posts about vaccines contain incorrect information.   

These findings are, perhaps, not surprising. But they are important to keep in mind as we doom-scroll for information about monkeypox. 

I’ve already seen a number of posts on Twitter claiming to have monkeypox breakthrough infections after vaccination. One author said they developed a monkeypox rash two weeks after vaccination. While this person’s experience was not likely a breakthrough case, the post brings up important questions. How much protection does a person have after being vaccinated and when? And, as some cities move to a one-dose regimen due to vaccine supply, what does research say about the number of doses needed to protect a person?

Monkeypox rashes and lesions can take up to three weeks to develop after exposure to the virus, which means it is possible the Twitter user mentioned above was exposed before vaccination or shortly after. The time following vaccination and when you are exposed to the virus matters in terms of the amount of protection you have. 

Simply put: vaccines do not offer protection immediately after being administered. Remember what we learned when getting our COVID-19 vaccines: no matter which vaccine you received, you were not fully protected until two weeks after the final dose. For the monkeypox vaccine the time to protection is actually longer. Clinical trials indicated it takes up to four weeks for patients to develop strong protection. In fact, two weeks after the first dose, the immune response was just 29 percent! Take extra care during this period to prevent spread.  

Now, what about one dose versus two? With limited monkeypox vaccine supply, cities and states should consider limiting doses to one per person to protect more people.

The U.S. Food and Drug Administration (FDA) approved a vaccine, Jynneos, developed by the U.S. government and Bavarian Nordic in 2019 to protect against both monkeypox and smallpox. The FDA recommended a two dose regimen, four weeks apart. This regimen outperformed an older smallpox vaccine (ACAM2000) for producing an immunological response. The Jynneos vaccine also has fewer side effects and is much safer.

Unfortunately, the Jynneos vaccine is in very short supply. Bavarian Nordic, the only manufacturer of the vaccine worldwide, says it can produce 30 million doses of Jynneos annually, meaning with a full regimen less than 15 million patients worldwide will have full protection. That’s why cities like Washington, D.C. and New York have chosen to move to a single-dose regimen. The United Kingdom and some countries in Europe have done the same.  

This approach is the right one. 

In clinical trials, recipients who were HIV negative had an 83 percent immune response 28 days after one dose compared to 98 percent with two doses at 42 days. HIV positive recipients had a 67 percent immune response 28 days after one dose. It was 96 percent 42 days after two doses. 

While that data indicates a two-dose regimen is best, with supplies limited, a one-dose regimen for most people is a reasonable approach. That strategy allows double the group of individuals to be immunized — even though there is slightly lower efficacy. A recent article in Science highlighted this important point. Jynneos’ CEO, an immunologist, said one dose of the vaccine conferred a “robust immune response.” 

There is one caveat, however. Based on the clinical trial data, we might need to stick with the original two-dose regimen for people who are immunocompromised or live with HIV (irrespective of immune status).

In the face of what appears to be a public health system in disarray, Americans need to be partners in fighting the virus’ spread. Get vaccinated when available. Individuals who are most at risk should sign up now to receive a vaccine. Second, understand it takes time after receiving the vaccine to develop immunity whether you are HIV positive or not. Understand monkeypox symptoms, the timing of symptoms and how to reduce your risk. And, of course, take care when it comes to social media. Spread truth.

Dr. N. Adam Brown is a practicing emergency medicine physician, founder of a healthcare strategy advisory group ABIG Health, and a professor of practice at the University of North Carolina’s Kenan-Flagler Business School. Previously he served as President of Emergency Medicine and Chief Impact Officer for a leading national medical group. Follow him on Twitter @ERDocBrown.

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