Tagged Disparities

Advocates View Health Care as Key to Driving LGBTQ Rights Conversation

When Allison Scott came out as a trans woman in 2013, she told not only family and friends, but also her primary care physician.

She didn’t need his help with hormone therapy. She had another doctor for that. But she wanted to share the information with her doctor of more than 10 years in case it affected other aspects of her health.

She was shocked when he told her he would no longer treat her.

“It was humiliating,” said Scott, now director of policy and programs for the Campaign for Southern Equality, an LGBTQ advocacy organization based in North Carolina. “It’s not because the provider doesn’t have the knowledge they need, but because the provider isn’t comfortable with who you are.”

Surveys in North Carolina and across the nation show that about one-third of transgender people have been refused treatment or suffered verbal or physical abuse from a medical provider.

Such concerns have become more worrisome during the covid-19 pandemic, when being denied health care — or avoiding it due to fear of discrimination and previous negative experiences — can have deadly consequences.

But Scott and other advocates in North Carolina now see an opening to push for city and county laws prohibiting this type of treatment. A state ban preventing local governments from enacting nondiscrimination ordinances expired on Dec. 1.

The ban was a remnant of the controversial 2016 “bathroom bill,” which catapulted North Carolina into the national spotlight by making it the first state to require transgender people to use the bathroom of the gender on their birth certificate. Although public backlash and economic repercussions forced the state to repeal that law, the legislature replaced it with one that blocked local governments from passing nondiscrimination ordinances.

Now new laws could address discrimination in employment, housing, public places and more. Scott said health care should be among the top considerations, whether that means banning discrimination on the basis of gender identity and sexual orientation in hospitals and clinics or preventing someone from being fired for their identity and losing health insurance as a result.

So far, the towns of Carrboro, Hillsborough and Chapel Hill, along with Orange County, jointly announced this month new nondiscrimination ordinances that will protect LGBTQ individuals in workplaces and in public. At least two other cities are drafting ordinances and plan to vote on them later this month.

These local actions take on added significance in view of efforts during the past four years to roll back federal protections for LGBTQ people. The Trump administration has tried to expand the interpretation of religious liberty and civil rights laws to protect medical providers who refuse to provide services for religious or moral reasons. Last summer, the administration reinterpreted the Affordable Care Act’s nondiscrimination requirements to remove Obama-era protections for LGBTQ people. This month, it removed explicit provisions that prohibited social service providers who receive Department of Health and Human Services grants from discriminating on the basis of sexual orientation and gender identity, among other characteristics. Sasha Buchert, a senior attorney with Lambda Legal, said the change affects a wide array of programs, from Meals on Wheels to child welfare agencies, HIV/AIDS services and more.

Although many of these actions have been blocked by courts, and the incoming Biden administration has promised to reverse several of Trump’s policies, LGBTQ advocates and legal experts say those processes take time and are not guaranteed.

“To put it plainly, having protections at the local level sometimes offers more protection, particularly as laws are being contested at the federal level,” said Lindsey Dawson, a researcher who studies LGBTQ issues at KFF. (KHN is an editorially independent program of KFF.)

For Michael Hoeben (right, holding child), the promise of nondiscrimination laws reaches beyond questions of access. Hoeben, a transgender man, says nondiscrimination laws can also send a clear message about what is acceptable in a community. (Michael Hoeben)

A Path Forward

In recent decades, protections for LGBTQ Americans have emerged as a cultural flashpoint, often triggering debates about religious liberties versus civil rights and involving anything from marriage and parenting to offices and bakeries.

Critics of nondiscrimination laws say they squash valid debate in health care about what constitutes ethical treatment.

Ryan Anderson, a senior research fellow with the conservative think tank the Heritage Foundation, said no one should be turned away from medical care because of their identity, but laws need to distinguish between that type of discrimination and medical providers who disagree on a certain treatment plan.

“If there’s an adult who wants to transition and a doctor and health care plan who want to support that, they can do that,” Anderson said. “But if the doctor or health plan don’t want to support that, they should also be free not to do that.”

For advocates who work with LGBTQ people daily, the need for nondiscrimination laws is clear. Ames Simmons, policy director for Equality NC, recounted the experiences of people he knows: One trans woman was threatened with arrest if she didn’t leave a hospital in the western part of the state, while another was denied care at a dialysis clinic in eastern North Carolina after she complained about harassment.

Research shows that LGBTQ people in states with nondiscrimination laws experience fewer disparities in employment, education and health care than those living in states without such laws. And city- and county-level actions may provide a road map for broader efforts. Christy Mallory, legal director at the Williams Institute at UCLA, pointed to the example of Utah, where a series of local ordinances eventually led the traditionally conservative state to pass a nondiscrimination law in 2015.

The laws don’t automatically change people’s beliefs, Mallory said, but they provide a starting point to build momentum toward statewide and cultural changes.

Ames Simmons, policy director for Equality NC, works with LGBTQ individuals daily. He personally knows at least two trans women who have been harassed while seeking medical care in the state — one threatened with arrest to leave a hospital, and one denied care at a dialysis clinic. (James Nichols)

Pandemic Urgency

Advocates cite an added imperative to protect LGBTQ rights because the covid pandemic has highlighted shortcomings and disparities in the nation’s health care system. A report by the Movement Advancement Project, a Colorado-based think tank, found 1 in 8 LGBTQ people have lost insurance coverage during the pandemic — twice the rate of non-LGBTQ people. Many are unable to afford hormone therapy or counseling. In some parts of the country, transgender people have reported mistreatment at covid testing sites.

Even before covid, transgender patients who came to Dr. Jennifer Abbott, a family physician at Western North Carolina Community Health Services in Asheville, often told her they had called as many as 10 other providers before finding someone willing to treat them. Abbott, who heads the clinic’s transgender health program, said about one-third of its approximately 400 patients come from rural areas across the western part of the state.

For some, the promise of nondiscrimination laws reaches beyond questions of access. The laws can also temper discriminatory behavior by sending a clear message about what is acceptable in a community, said Michael Hoeben, who coordinates services for transgender and HIV patients at the clinic and is a transgender man.

Once, when Hoeben was having a cervical polyp removed, the doctor asked him what it meant to be transgender. The doctor and nurse proceeded to laugh at Hoeben’s response while performing the procedure, he said. Hoeben was so mortified that he avoided seeing a doctor for the next seven years.

A law may not have prevented that experience, Hoeben said, “but without the law, it’s like open season.”

“For your local government to pass a law that says we see you, we recognize you and we include you,” Hoeben said, “that is a level of safety you’re constantly seeking as a trans person.”

Aunque controlen el Senado, demócratas necesitarán apoyo republicano en temas clave de salud

Ante la pandemia, los demócratas han abogado por ayudas más generosas, más presión sobre las farmacéuticas para que bajen los precios y más atención al racismo sistémico en la atención de salud.

El 20 de enero, con el control del Senado y la Cámara de Representantes, tendrán el poder de elegir qué propuestas de salud se votarán en el Congreso.

Las victorias del reverendo Raphael Warnock y Jon Ossoff en Georgia dieron a los demócratas dos escaños más en el Senado y la ventaja en un Senado dividido 50-50. Cuando la vicepresidenta electa, Kamala Harris, jure el cargo, su voto servirá como desempate, convirtiéndose así en el voto 51 de los demócratas.

Pero este estrecho margen de votos no eliminará el “filibusteo” (discursos obstruccionistas y dilatorios), lo que significa que los demócratas no tendrán suficientes votos para aprobar muchos de sus planes sin los republicanos.

Eso pondrá en peligro muchas propuestas demócratas de salud, como la de ofrecer a los estadounidenses una opción de seguro público patrocinada por el gobierno, y complicará los esfuerzos para aprobar más ayudas para la pandemia.

Queda por ver si los legisladores serán más proclives al compromiso después que una turba pro-Trump invadiera el Capitolio, el 6 de enero, atacando a la policía y dañando propiedad federal. Hubo cinco muertos.

Los estrechos márgenes de los demócratas en el Senado y en la Cámara de Representantes — donde pueden permitirse perder cuatro votos y aun así aprobar una legislación— también darán más influencia a algunos legisladores que, al no estar de acuerdo con los líderes de sus partidos, tendrán un incentivo para impulsar sus propias agendas a cambio de sus votos.

Habrá poco espacio para los desacuerdos intrapartidarios; y los demócratas dejaron claro, durante las primarias presidenciales, que no están todos de acuerdo sobre cómo lograr sus objetivos de salud pública.

En menos de dos semanas, los demócratas dirigirán los comités encargados de establecer la legislación sobre salud y de examinar a los nominados de Biden en esta área.

El control del Comité de Salud, Educación, Trabajo y Pensiones del Senado pasará a la senadora Patty Murray, demócrata de Washington, quien negoció el acuerdo de 2013 con el entonces presidente de la Cámara de Representantes, Paul Ryan, que puso fin a un largo cierre del gobierno, entre otros acuerdos bipartidistas.

En 2019, Murray y el presidente republicano del comité, el senador Lamar Alexander, de Tennessee, introdujeron un amplio paquete legislativo para reducir los costos de salud. Entre sus propuestas se encontraba una iniciativa para bajar los precios de los medicamentos recetados, mediante la eliminación de las lagunas legales que permiten a los fabricantes de medicamentos de marca bloquear a la competencia.

Durante una entrevista, antes de que los demócratas se aseguren el Senado, Murray dijo que el trabajo de su comité se centrará en los problemas que impiden a los estadounidenses recibir un tratamiento médico equitativo y asequible.

La prioridad, dijo, serán las disparidades raciales, evidenciadas por los desproporcionados índices de mortalidad entre las madres de raza negras, y entre las comunidades de color, que sufren los peores impactos de la pandemia de covid-19.

“No todos los que acuden al médico reciben la misma atención, sienten el mismo nivel de comodidad y muchas veces no se les cree”, dijo Murray.

Murray aseguró que presionará a los senadores para que consideren el impacto en las comunidades de color de cada pieza legislativa. “Esa será la cuestión en cada paso que demos”, añadió.

El miércoles 6, pidió a los republicanos que se incorporen a la lucha contra la pandemia “con políticas que ayuden directamente a los que más sufren y que nos ayuden a salir de esta crisis con más fortaleza y justicia”.

“Con una administración Biden-Harris y una mayoría demócrata en el Senado, los desafíos que enfrentamos no serán menores, pero finalmente tenemos la oportunidad de enfrentarlos y comenzar a tomar medidas”, declaró Murray. “Estoy deseando ponerme manos a la obra”.

El Comité de Finanzas del Senado, que supervisa Medicare, Medicaid y las políticas fiscales relacionadas con la salud, estará encabezado por el senador Ron Wyden, demócrata de Oregon.

Si bien el comité HELP también celebrará una audiencia de confirmación para Xavier Becerra, el candidato de Biden a la Secretaría del Departamento de Salud y Servicios Humanos; es el Comité de Finanzas el que votará para avanzar su confirmación.

En diciembre, los republicanos del Senado amenazaron con retrasar la nominación de Becerra antes de que Biden lo anunciara oficialmente. Los republicanos le reprochan a Becerra su falta de experiencia en el campo de la salud, cuestionan su apoyo a un sistema de salud de un solo pagador y se oponen a su defensa del derecho al aborto.

Como fiscal general de California, Becerra se enfrentó a las demandas presentadas por los funcionarios estatales republicanos contra la Ley de Cuidado de Salud A Bajo Precio (ACA).

Pero se espera que la escasa ventaja de los demócratas en el Senado sea suficiente para rechazar las objeciones de los republicanos a la nominación.

El mes pasado, Wyden alabó el compromiso de Becerra para responder a la pandemia, proteger la cobertura de los cuidados de salud y abordar las disparidades raciales; y dijo que esperaba con interés la audiencia de Becerra “para que pueda ponerse a trabajar y empezar a ayudar a la gente durante esta crisis sin precedentes”.

Además, después de meses de denunciar los fracasos de la administración Trump en el manejo de la pandemia, los demócratas controlarán qué proyectos de ley de ayuda se votarán.

El paquete del mes pasado no incluyó sus demandas de más fondos para los gobiernos estatales y locales, y los republicanos de la Cámara de Representantes bloquearon una iniciativa demócrata que pretendía aumentar los cheques de estímulo de $600 a $2,000.

Los demócratas se han unido en sus demandas de más ayuda, aunque a veces han estado en desacuerdo sobre cómo llevarla a cabo.

En el otoño, con las elecciones cerca y sin ningún acuerdo a la vista, los demócratas moderados, que buscaban ganar su propia elección, presionaron a la presidenta de la Cámara de Representantes, Nancy Pelosi, para que abandonara las negociaciones por un paquete de ayuda de $2,2 billones, que los republicanos calificaron como un fracaso, y aprobara una ayuda más modesta pero desesperadamente necesaria.

“Tanto el liderazgo demócrata, como el republicano, ha metido la pata. Todos son responsables”, declaró a Politico el representante Max Rose, demócrata de Nueva York. “Hagan algo ¡Hagan algo!” Rose perdió la reelección.

Voces más progresistas, como la de la representante Alexandria Ocasio-Cortez, demócrata de Nueva York, y el senador Bernie Sanders, independiente de Vermont, han presionado a favor de una ayuda más generosa, con mayores cheques de estímulo.

Más allá de la pandemia, el liderazgo demócrata ha mencionado el precio de los medicamentos como otra área de acción. Pero una de sus propuestas más populares, que autorizaría al gobierno federal a negociar los precios de los medicamentos para quienes están en Medicare, es poco probable que atraiga los votos republicanos que necesitaría.

Cuando los demócratas de la Cámara de Representantes aprobaron una de estas propuestas en 2019, los senadores republicanos aseguraron que ellos nunca la aprobarían.

Los miembros del ala más progresista de los demócratas, por su parte, argumentaron que la propuesta no era suficientemente agresiva.

Sin embargo, después de años de esfuerzos republicanos por socavar ACA, parece probable que la estabilización de la ley pueda cobrar fuerza en un Congreso controlado por los demócratas.

La Cámara de Representantes aprobó, el verano pasado, una legislación destinada a aumentar la cobertura y la asequibilidad, incluyendo la limitación de los costos de los seguros a no más del 8,5% de los ingresos y la ampliación de los subsidios.

Legisladores como Murray y Wyden se han apresurado a señalar que las consecuencias devastadoras de la pandemia, la pérdida de puestos de trabajo y la pérdida de cobertura del seguro, por nombrar sólo dos, han puesto de relieve la necesidad de fortalecer el sistema de salud.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Even With Senate Control, Democrats Will Need Buy-In From GOP on Key Health Priorities

Democrats have argued for more generous pandemic relief, more pressure on drugmakers to lower prices and more attention to systemic racism in health care. On Jan. 20, with control of the Senate and the House of Representatives, they’ll have the power to choose which health care proposals get a vote in Congress.

The victories of the Rev. Raphael Warnock and Jon Ossoff in Georgia last week gave Democrats two more Senate seats and the upper hand in the Senate’s now 50-50 split. After Vice President-elect Kamala Harris takes the oath of office, she will serve as the tiebreaker as needed — in effect, Democrats’ 51st vote.

But that vote count is too small to eliminate the filibuster, meaning Democrats will not have enough votes to pass many of their plans without Republicans. That will likely doom many Democratic health care proposals, like offering Americans a government-sponsored public insurance option, and complicate efforts to pass further pandemic relief.

It remains to be seen how willing lawmakers are to compromise with one another in the aftermath of a pro-Trump mob’s breach of the Capitol on Wednesday. Thursday, Democrats demanded the president’s removal for inciting rioters who disrupted the certification of President-elect Joe Biden’s victory, assaulted Capitol Police officers and damaged federal property. One demonstrator and a police officer were killed, and three demonstrators died of medical emergencies.

Democrats’ slim margins in the Senate and the House — where they can afford to lose only four votes and still pass legislation — will also give individual lawmakers more leverage, handing those who disagree with party leaders an incentive to push their own priorities in exchange for their votes. There will be little room for intraparty disagreements, and Democrats made it clear during the presidential primaries that they disagree about how to achieve their health care goals.

In less than two weeks, Democrats will lead the committees charged with marking up health care legislation and vetting Biden’s health nominees.

The change will hand control of the Senate Health, Education, Labor and Pensions Committee to Sen. Patty Murray (D-Wash.), who brokered the 2013 agreement with then-House Speaker Paul Ryan that ended a long government shutdown, among other bipartisan deals.

In 2019, Murray and the committee’s Republican chairman, Sen. Lamar Alexander of Tennessee, introduced a wide-ranging package to lower health costs for consumers. Among its proposals was an initiative to lower prescription drug prices by eliminating loopholes that allow brand-name drugmakers to block competition.

In an interview before Democrats secured the Senate, Murray said her committee work will be focused on the problems that prevent all Americans from receiving equitable, affordable treatment in health care. Racial disparities, evidenced by disproportionate mortality rates among Black mothers and among communities of color suffering the worst impacts of the pandemic, will be a priority, she said.

“Not everybody goes into the doctor and gets the same advice, feels the same comfort level and is believed,” Murray said.

Murray said she will press for senators to consider how any piece of legislation will affect communities of color. “It will be the question I ask about every step we take,” she said.

On Wednesday, she called out Republicans for standing in the way of fighting the pandemic “with policies that would directly help those struggling the most and would help us build back from this crisis stronger and fairer.”

“With a Biden-Harris Administration and a Senate Democratic majority, the challenges we face won’t get any less tough — but we’ve finally got the opportunity to face them head on and start taking action,” Murray said in a statement. “I can’t wait to start getting things done.”

The Senate Finance Committee, which oversees Medicare, Medicaid and health-related tax policies, will be run by Sen. Ron Wyden (D-Ore.). While the HELP committee will also hold a confirmation hearing for Biden’s nominee for secretary of the Department of Health and Human Services, Xavier Becerra, it is the Finance Committee that will vote to advance his confirmation.

Senate Republicans signaled they would delay considering Becerra’s nomination before Biden officially announced his name last month. Calling him unqualified due to his lack of a health care background, they questioned his support for a single-payer health care system and opposed his efforts to preserve abortion rights. As California’s attorney general, Becerra led efforts to fight lawsuits brought by Republican state officials against the Affordable Care Act.

But Democrats’ slim edge in the Senate is expected to be enough to drown out Republicans’ objections to the nomination. Last month, praising Becerra’s commitment to responding to the pandemic, protecting health care coverage and addressing racial disparities, Wyden said he looked forward to Becerra’s hearing “so he can get on the job and start helping people during this unprecedented crisis.”

Also, after months of decrying the Trump administration’s failures managing the pandemic, Democrats will control which relief bills get a vote.

Last month’s package did not include their demands for more funding for state and local governments, and House Republicans blocked a Democratic effort to increase stimulus checks to $2,000, from $600.

Democrats have been united in their calls for more assistance, though they have disagreed at times about how to push for it.

In the fall, with the election approaching and no deal in sight, moderate Democrats in tough races pushed for House Speaker Nancy Pelosi to abandon negotiations for a $2.2 trillion relief package that Republicans called a nonstarter in favor of passing more modest but desperately needed relief.

“Every member of the leadership team, Democrats and Republicans, have messed up. Everyone is accountable,” Rep. Max Rose (D-N.Y.) told Politico. “Get something done. Get something done!” He lost his bid for reelection.

More progressive voices like Rep. Alexandria Ocasio-Cortez (D-N.Y.) and Sen. Bernie Sanders (I-Vt.) have been a force for more generous aid, particularly larger stimulus checks.

Beyond the pandemic, top Democrats have mentioned drug pricing as another area ripe for action. But one of their most popular proposals, which would authorize the federal government to negotiate drug prices for those on Medicare, is unlikely to attract the Republican votes it would need. When House Democrats passed one such proposal in 2019, Senate Republicans vowed it would never pass.

Members of Democrats’ more progressive wing, for their part, argued the proposal may not go far enough.

After years of Republican efforts to undermine the Affordable Care Act, though, it looks likely that efforts to stabilize the law could gain more traction under a Democratic-controlled Congress. The House passed legislation last summer aimed at increasing coverage and affordability, including by capping insurance costs at no more than 8.5% of income and expanding subsidies.

Lawmakers like Murray and Wyden have been quick to point out that the pandemic’s devastating consequences — lost jobs and lost insurance coverage, to name just a couple — have only underscored the need to strengthen the health care system.