The overlapping issues of health care and employment discrimination remain pivotal ones for transgender communities. They became more so last month, when the Trump administration decided to allow states to institute work requirements for Medicaid.
The unemployment rate for trans people is three times higher than the national average, according to a 2015 survey produced by the National Center for Transgender Equality — a rate that results, in many cases, from anti-trans job discrimination. These new rules create a double bind for the most vulnerable trans people: Find work amid rampant prejudice and mistreatment, or lose critical medical coverage.
In Kentucky, the first state to adopt work requirements, one in four transgender people report losing a job, being passed over for a promotion or not being hired because they are trans. The majority of states considering adopting work requirements are among the 30 in which gender identity is not considered a protected category. Of the 10 states currently carrying out or proposing Medicaid work requirements, only two — Maine and Utah — have an employment nondiscrimination law in place that protects trans workers. In contrast, Arkansas and North Carolina have state-level bans on local nondiscrimination ordinances that would safeguard the rights of queer and trans communities.
Statistics regarding transgender people who lose their jobs because of their gender identities reveal only the cases in which such bias was blatant. Lost within these numbers are the more ambiguous stories — of managers who may have rejected a request for a uniform that reflected an employee’s gender, workers terminated for requests to change their names on internal documents or employees whose presence was shown, through the actions of colleagues and superiors, to be unwelcome.
These stories aren’t quantifiable, but they are common. These statistics also fail to factor in the basic administrative challenges unique to trans workers, who can be subject to outsize scrutiny during hiring because of discrepancies in identity documents, with their names or gender markers varying from official documents. This is particularly true in Kentucky, where nearly four in five trans people do not have identity documents that match their name and gender.
Seema Verma, the administrator for the Centers for Medicare and Medicaid Services, says that new regulations are needed because the addition of able-bodied adults without children to Medicaid under the Affordable Care Act has jeopardized the program for those whose medical conditions make them unable to work.
But trans people may be legally excluded from this population as well. Being trans itself is not a disability. But many trans people have a condition called gender dysphoria, defined in the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders” as a “marked incongruence between one’s experienced/expressed gender and assigned gender.” This condition can be disabling: The challenges of renegotiating everyday life while in the process of transition, often while being subjected to discrimination, can be psychologically extreme. It can also be expensive: Without insurance, transition costs can run into the tens of thousands of dollars.
Yet gender dysphoria is not recognized under the current Americans with Disabilities Act, which is supposed to protect against discrimination, and although some transgender claimants have been allowed to file under existing disability law, many others have been excluded. It is unclear whether gender dysphoria will be among the disabilities to which Ms. Verma refers, an opacity that, in itself, will discourage many trans people from seeking the program’s protection.
Medicaid work requirements, coupled with a lack of legal protections for those dealing with a potentially disabling condition, leaves trans people in an untenable position: In order to receive health care, those able to work must seek employment in places that offer them few protections against discrimination, while those who are unable to work face expensive medical bills and may have nowhere to turn
Medicaid work requirements are an attempt to roll back the Affordable Care Act’s expansions in medical coverage. But when employers essentially have free rein to punish trans people for being trans, such requirements be cannot be considered fair.
Ms. Verma asserts that Medicaid work requirements are “about helping people achieve the American dream.” They are far more likely to dehumanize trans people and prevent Americans from accessing necessary medical care.