Connect with us

Opinions

Navigating employer-sponsored health insurance, care

One in four trans patients denied coverage for gender-affirming care

Published

on

(Photo by maxxyustas/Bigstock)

Even though 86% of transgender Americans have health insurance, one in four reported being denied coverage for gender-affirming care in the 2015 and 2022 U.S. Transgender surveys. These denials can occur when an insurance plan contains a categorical exclusion of gender-affirming care. It is important to note that transgender employees who receive insurance coverage through their employers are entitled to legal protections. 

Employers are responsible for ensuring that the insurance plans they provide do not violate any laws, including anti-discrimination laws. In 1983, the Supreme Court ruled that under Title VII of the Civil Rights Act of 1964, employers are legally required to provide employees with equal pay and benefits, including health insurance. This protection now extends to transgender employees after the Supreme Court’s ruling in Bostock v. Clayton County (2020), which clarified that sex discrimination under Title VII includes gender identity discrimination.

Since Bostock, several transgender employees have successfully sued their employers for discrimination because they were denied coverage of gender-affirming care by their employers’ insurance. While employers can be held liable under Title VII, it remains unclear whether insurance companies will be held liable under Section 1557, the antidiscrimination provision of the Affordable Care Act (ACA), in the future.

Most—if not all—courts have ruled that employers can be held liable for choosing insurance plans with categorical exclusions of gender-affirming care. A categorical exclusion is when an insurance plan has a blanket ban of coverage for certain services. Although discrimination cases generally require proof of intent to discriminate, it is not required of transgender employees because categorical exclusions of gender-affirming care are facially discriminatory (i.e. the policy is explicitly and obviously discriminatory in nature).

In Kadel v. Folwell (2024), the Fourth Circuit court considered the Fourteenth Amendment, Title IX, and ACA claims in a consolidated case considering two state health plans: the State of North Carolina’s insurance plans for teachers and West Virginia’s Medicaid program. The Fourth Circuit court held that it is impossible to ban coverage of gender-affirming care without discriminating against transgender people because (1) gender dysphoria is a legitimate medical diagnosis which requires medically necessary treatment; and (2) the services provided under gender-affirming care are also provided to cisgender patients for other medical diagnoses. In short, there is sufficient evidence of discriminatory intent because categorical exclusions of gender-affirming care are facially discriminatory. Under Kadel, the Fourth Circuit also ruled that a policy does not have to explicitly exclude transgender patients. “Rewording the policies to use a proxy,” like sex changes or sex modification, is still facially discriminatory.

Along a similar vein, in Lange v. Houston County (2024), the Eleventh Circuit court found that the Sheriff’s Office’s categorical exclusion of gender-affirming care was a violation of Title VII. Agreeing with the reasoning in Kadel, the court cited a 1991 Supreme Court Case which ruled that proof of intent to discriminate is not needed for facially discriminatory policies. The court also held Anthem Blue Cross liable because third-party administrators in the Eleventh Circuit (i.e., Alabama, Florida, and Georgia) can be held liable as an employer if they make employment decisions as the authorized agent of an employer. However, this decision is unique to the said jurisdictions, and the liability of third-party administrators/insurance providers remains generally unclear. Moreover, the decision is not final because the court granted an en banc appeal, and a panel of all twelve judges re-heard the case in February 2025. The decision after re-hearing remains to be seen. 

Recently, Executive Order 14168 and the EEOC’s motion to dismiss its lawsuit against Harmony Hospitality on behalf of a transgender worker prompted concerns over transgender employees’ ability to bring federal discrimination claims. While such concerns are understandable, there has yet been any mandate prohibiting the EEOC from issuing right to sue to transgender individuals. In other words, even if the EEOC may not investigate and file lawsuits on behalf of transgender individuals, it does not bar private parties from doing so. Ultimately, the executive branch alone does not have the power to make changes to the Constitution or any federal statutes. It is up to the legislatures to amend laws and the Constitution, and courts to interpret and rule on constitutionality. 

Protections Against Discrimination by Insurers Under Section 1557 Remain Unclear

While employers can be held liable for categorical exclusions of gender-affirming care, employees may be less likely to find relief for legal claims against insurers regarding discrimination on the basis of gender identity. Since Bostock, courts have found insurers liable for denying coverage of gender affirming care under Section 1557 of the ACA, extending sex discrimination to include gender identity. Recent litigation surrounding Section 1557 and the new presidential administration may precede a change in this trend.

In May 2024, the Biden administration issued a final rule implementing Section 1557.It reversed the rule put forth by the Trump administration four years prior, which had revised the Obama administration’s interpretation of the statute. The Biden administration’s final rule defined sex discrimination to include discrimination on the basis of gender identity and sexual orientation. Additionally, under the new rule, a wider swath of insurers and third-party administrators that receive federal financial assistance would be subject to Section 1557. 

However, in July 2024, a Mississippi District judge granted a nationwide injunction preventing the Department of Health and Human Services from enforcing the final rule’s prohibition of sex discrimination with respect to gender identity. Additionally, executive orders during the early days of the Trump administration, and guidance from the Department of Health and Human Services that followed, rescinded wide swaths of Biden-era guidance extending sex discrimination protections to include discrimination based on gender identity. It is not yet clear how the new administration’s position on Section 1557 will impact courts’ decision-making regarding insurer liability and the extent of sex discrimination provisions in relation to gender identity going forward. 

As the recent history of Section 1557 demonstrates, executive actions may influence the implementation of statutory antidiscrimination provisions, but do not change the law itself. While employers continue to face liability for discrimination towards employees seeking insurance coverage of gender-affirming care under Title VII, some protections remain on less certain ground as the United States enters a new presidential administration. 


Ting Cheung, Luke Lamberti, and Neha Sharma are with Sanford Heisler Sharp McKnight.

Advertisement
FUND LGBTQ JOURNALISM
SIGN UP FOR E-BLAST

Opinions

Tennessee’s Charlie Kirk Act is harmful

Free speech doesn’t always go both ways

Published

on

Tennessee State Capitol Building (Photo by SeanPavonePhoto/Bigstock)

The state of Tennessee has a long history of political discrimination against its 225,000 LGBTQ citizens. In 2019, a district attorney remarked that gay people should not receive domestic violence protections, and in 2023, for five months in Murfreesboro, homosexual acts in public were illegal, prompting a federal judge to have the ordinance removed.

In 2022, I briefly lived in Tennessee and played rugby with the LGBTQ-inclusive Nashville Grizzlies, who welcomed me with open arms as an ally, teaching me that rugby isn’t always about winning or losing – it’s about creating a safe, inclusive, and joyful space for people looking to feel welcome.

In Tennessee, where 87% of the LGBTQ community has experienced workplace discrimination, and where, each year, countless bills that target their identities are introduced, it can be difficult to feel welcome. The Nashville Grizzlies played rugby with the exuberance of newly liberated people who were finally able to be their authentic selves. I was inspired by their brotherhood. 

When I read about the Charlie Kirk Act being passed last week, I felt a visceral need to write about it. 

While the bill is presented as legislation that strengthens free speech and encourages greater public discourse on campuses, it would effectively allow a school to expel a student who felt compelled to walk out on a speaker with hateful views, forcing marginalized groups to sit through existentially harmful rhetoric. 

And ironically, it doesn’t seem like free speech goes both ways — a Tennessee University administrator lost their job last year for sharing negative views on Charlie Kirk, and countless LGBTQ books have been banned not only in schools, but even in adult libraries.

We like to think that as time moves forward, progress is inevitable, but this isn’t always the case. In a 2023 study, 27% of LGBTQ Tennesseans and 43% of transgender people in the state have considered relocating, forcing them to reckon with leaving home in pursuit of a better life. Nashville Grizzlies Captain Ethan Thatcher told me, “I’ve thought about leaving Tennessee. Hard not to when the government does not want you here. What has kept me here is the Grizzlies community, and the thought that existence is resistance.”

Everybody in our country deserves to feel safe. I thought that was a core value of the American ethos, but apparently, in some states, certain groups are welcome while others are ostracized. 

Tennessee Gov. Bill Lee should reject the Charlie Kirk Act.


Tyler Kania is a 2025 IAN Book of the Year nominated author and civil rights activist from Columbia, Conn.

Continue Reading

Opinions

The latest Supreme Court case erasing LGBTQ identity

Chiles v. Salazar a major setback for movement

Published

on

(Washington Blade photo by Michael Key)

In its recent decision in Chiles v. Salazar, the U.S. Supreme Court invalidated Colorado’s law prohibiting licensed counselors from engaging in efforts to change the sexual orientation or gender identity of minors. The decision, which puts into question similar laws in 22 other states, relied on the First Amendment to hold that the law violates counselors’ free speech rights. But the decision also strikes a blow against LGBTQ dignity, a point the court’s opinion does not even address.  

The eight-member majority, which included Justices Elena Kagan and Sonia Sotomayor, who usually side with LGBTQ groups, justified its reasoning by suggesting that the law was one-sided: it permitted treatment that affirms LGBTQ identity but forbade treatment that seeks to change it. But the law is one-sided, as Justice Ketanji Brown Jackson’s lone dissent pointed out, because the medical evidence only supports one side: reams of research show that “survivors of conversion therapy continue to suffer from PTSD, anxiety, and suicidal ideation.” And major medical associations all agree, no evidence demonstrates the efficacy of conversion efforts. This isn’t surprising. Medicine often take sides — some treatments work, and some don’t.

But particularly concerning is the vision of LGBTQ identity that undergirds the majority opinion when compared to the dissent. Justice Jackson’s dissent explains that LGBTQ identity is simply “a part of the normal spectrum of human diversity” — not something to be “cured.” By contrast, for the majority, how best to help LGBTQ minors is “a subject of fierce public debate.” That can hardly be the case if LGBTQ identity stands on equal ground with straight, cisgender identity, or if LGBTQ people are as deserving of safety, rights, and dignity.

Indeed, the LGBTQ rights movement only began in earnest when advocates in the 1960s decided to end the “debate” over gay identity. Until then, community leaders would routinely cooperate with psychiatrists who were interested in researching homosexuality as a medical condition. A new generation of activists, led by Frank Kameny, a key movement founder, began arguing that this got the issue upside down: Rather than wondering if they could be “cured,” LGBTQ people had to assert a right to their identity. As Kameny put it—“we have been defined into sickness.” Only once the case was made that it was society that had to change, and not LGBTQ people, could LGBTQ consciousness, LGBTQ pride and LGBTQ rights develop. Their activism led to the first Pride parade in New York, and the official declassification of homosexuality as a disease in 1973. 

The Supreme Court’s conservatives don’t just want to reignite this half-century old medical “debate”; they also treat medical claims that undermine LGBTQ identity very differently from those who support it. Last year, in an opinion backingTennessee’s law that banned gender affirming care for minors, the court sympathetically marched through the reasons Tennessee offered for “why States may rightly be skeptical” of such care, and cited three times, in some detail, to “health authorities in a number of European countries” (that is, some Nordic countries and the UK) that had curbed pediatric care. It failed to mention that most of Western Europe and every major American medical association provides access to this care.

In Chiles, by contrast, the court cites none of the evidence that Colorado amassed that conversion therapy harms LGBTQ children. None of the countries that the court had invoked to justify anti-trans policies allow conversion therapy in their health care systems (indeed, one of them criminalizes such practices). So rather than cite medical evidence, the court simply asked — why trust medical evidence at all? “What if,” asks the court, “reflexive deference to currently prevailing professional views [does] not always end well?” and cites an infamous 1927 Supreme Court case, Buck v. Bell.

In Buck, the Supreme Court embraced eugenic reasoning, backing a eugenic state law that allowed the sterilization of individuals with mental disabilities, on the grounds that such disabilities were hereditary. As Justice Oliver Wendell Holmes opined, “three generations of imbeciles are enough.” Look at what happens when we listen to medical expertise, today’s court seems to say, as an excuse to disregard the LGBTQ-affirming medical evidence they don’t like.

But the court has missed the key lesson of Buck. The law at issue in Buckdiscriminated against a certain group, seeking, through sterilization measures, to erase it from existence. Indeed, LGBTQ people (whom doctors of the day would have referred to as sexual “inverts”) were exactly the kind of people that the eugenic program of Bucksought to eliminate. Conversion therapy seeks similar erasure.

The lesson of the 1960s LGBTQ rights movement remains as relevant today as it was then. Without an unapologetic LGBTQ identity, LGBTQ Pride, LGBTQ rights and the LGBTQ movement itself can all founder. By supporting only the anti-LGBTQ side in this medical saga — and by suggesting that LGBTQ existence is subject to medical debate at all — the court is reaffirming, rather than repudiating, minority erasure.


Craig Konnoth is a professor of law at University of Virginia School of Law.

Continue Reading

Opinions

Response to a personal attack against me

Writers should stick to facts and reason

Published

on

(Photo by sqback/Bigstock)

I was disappointed when the Blade didn’t publish my response to a personal attack on me in a column by Hayden Gise, in last week’s print edition. They did publish it online. To be clear, I have no problem with people disagreeing with my columns and opinions. That is absolutely fair. But when they get into personal attacks, it often means they don’t have enough to say about the ideas they are trying to criticize. 

In a recent column ‘Why the Democratic Socialists of America are right for D.C.,’ the author decided to attack me personally. Here is the response I wrote to her column: 

“I am responding to a column by Hayden Gise who says in her column she is a transgender, lesbian, Jewish, Democratic Socialist, and supports having the Democratic Socialists of America (DSA) in Washington, DC. She is definitely as entitled to her view on this, as I am to mine. However, I was surprised she clearly felt it important to use the column to attack me personally, without even knowing me. What she didn’t do is respond to the issues in the DSA platform I wrote having a problem with, and which I asked candidates endorsed by the DSA to respond to. 1. Are they for the abolishment of the State of Israel? 2. What is their definition of a Zionist? 3. What is their definition of antisemitism? 4. Will they meet with Zionist organizations? 5. Do they support BDS? One needs to know when a candidate claims they are only a member of the local DSA, according to the DSA bylaws no person can be a member of a local DSA without being a member of the national organization. So Hayden Gise has a little better idea of who I am she should know: I was a teacher and a union member. I worked for the most progressive member of Congress at the time, Bella S. Abzug (D-N.Y.), and supported her when she introduced the Equality Act in 1974, to protect the rights of the LGBTQ community, and have fought for its passage ever since. I have spent a lifetime fighting for civil rights, women’s rights, disability rights, and LGBTQ rights. I have no idea what Hayden Gise’s background is, or what her history of working for the causes she espouses is. But I would be happy to meet with her to find out. But she should know, I take a back seat to no one in the work I have done over my life fighting for equality, including economic equality, for all. So, I will not attack her, as I don’t know her, and contrary to her, don’t personally attack people I don’t know much about. 

“I have, and will continue to attack, what the government of Israel is doing to the Palestinian people, and now to those in Lebanon and Iran. I will also attack the government of my own country, and the felon in the White House, and his sycophants in Congress, for what they are doing to our own people, and people around the world, and will continue to work hard to change things. However, I will also continue to stand for a two-state solution with the continued existence of the State of Israel, calling for a different government in Israel. I also strongly support the Palestinian people and believe they must have the right to their own free state.”

I have not heard from Gise, but I hope she knows that since she wrote her column indicating her support for Janeese Lewis George for mayor, her preferred candidate has attended a birthday party to celebrate a person who still refers to gay people as ‘fags.’   

We should not personally attack people we don’t know as a way to criticize their views on an issue. Once again, I have no problem with people disagreeing with what I write, and having the Blade publish those contrary columns. But a plea to all who disagree with any columnist, or story: disagree with the issues and refrain from making personal attacks on the writer. That actually takes away from whatever point you are trying to make. 


Peter Rosenstein is a longtime LGBTQ rights and Democratic Party activist. 

Continue Reading

Popular