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Moral Progress in the Public Safety Net: Access for Transgender and LGB Patients by Stephan Davis and Nancy Berlinger
A
s a population, people who self-identify as lesbian, gay, bisexual, or transgender face significant risks to health and difficulty in obtaining medical and behavioral health care, relative to the general public. Commonly cited risks include higher rates of homelessness and of suicide attempts among youth, of sexually transmitted infections and substance abuse, and of being the target of violence.1 Within this population, transgender people are far more likely to express concerns about how they will be treated when they seek health care. A survey conducted by Lambda Legal in 2009 found that, among nearly five thousand total respondents, “transgender or gender-nonconforming respondents reported experiencing the highest rates of discrimination and barriers to care.”2 This survey also found that LGBT people of color or with low incomes were more likely to experience “discriminatory and substandard care.”3 It is therefore not surprising that transgender people of color and transgender people who are low income experience extremely high rates of discrimination in health care. Over 80 percent of low-income or uninsured transgender respondents to the Lambda Legal survey felt that they would be treated “differently” from other patients when they sought health care; this was also a significant concern of higher-income transgender people (68 percent) and of greater concern to low-income gay, lesbian, or bisexual people (39 percent) than to higher-income gay, lesbian, or bisexual people (26 percent).4 These issues are especially challenging in safety-net health care institutions, which serve a range of vulnerable populations with limited access, limited options, and significant health disparities. Safety-net hospitals, particuStephan Davis and Nancy Berlinger, “Moral Progress in the Public Safety Net: Access for Transgender and LGB Patients,” LGBT Bioethics: Visibility, Disparities, and Dialogue, special report, Hastings Center Report 44, no. 5 (2014): S45-S47. DOI: 10.1002/hast.370
larly public hospitals with fewer resources than academic medical centers and other nonprofit hospitals that also serve as safety nets, are under immense financial pressures for multiple reasons. For one, the Affordable Care Act mandated reductions in payments to disproportionateshare hospitals, which serve large numbers of uninsured patients, yet there is no certainty that these reductions will be offset by the newly insured, especially in states that have refused the ACA’s Medicaid expansion. In addition, a consequence of the “two-midnight rule” of the Centers for Medicare and Medicaid Services, a policy that aims to limit hospital admissions to patients who require at least two nights of inpatient care, is that hospitals are assigning more patients to “observation” status at a lower Medicare reimbursement rate to avoid being financially penalized by Medicare auditors. Safety-net patients often have limited options for needed postdischarge care, putting them at high risk of readmission, which triggers other financial penalties. Public hospitals also have to invest in infrastructure to support patient care, regulatory compliance, and information technology upgrades with fewer resources than other hospitals. From the hardnosed perspective of service utilization, how much incentive do cash-strapped public hospitals have to invest in care for a population whose members may need medical services not covered by public insurers or who may be perceived as time-consuming to “manage” or as “difficult,” requiring more of the limited resource of staff time? The answer, historically, has been “very little.” However, with the introduction in 2011 of standards for LGBT inclusion by The Joint Commission, showing progress on LGBT health care has become a compliance issue for hospitals.5 And because the health care community itself has contributed to LGBT health disparities through prejudice, disrespect, or inadequate knowledge that have made it difficult for LGB and especially T peo-
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
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ple to seek care or to obtain the care they need, there is a moral case for allocating scarce resources to this population: we owe them some investment in righting wrongs that the health care system itself has produced. So, where to begin in the typical safety-net hospital or clinic? Beyond staff training, which is essential and for which good models now exist, what does justice demand from a service-utilization perspective? Given the range of health care services that an LGBT person in the safety net may need or want, how should we set priorities? And what can’t we promise to do for this member of our community? For example, the range of medical treatments that may be part of gender transition are not yet consistently described and reimbursed by insurers. Under an important May 2014 ruling, Medicare now covers transition-related medical care, including sex reassignment surgery and hormone therapy, and private insurers who do not already do so are likely to follow Medicare’s lead, as is common with other treatments. Whether insurers should pay for procedures characterized as “cosmetic” continues to be debated. For instance, a person transitioning from female to male may consider undergoing a chin implant to acquire a more masculine appearance. A male who is not transitioning may wish to have the same procedure for the same reason. It is hard to make the case that insurance should cover the procedure for one man, while the other man should pay out of pocket. But in the public safety net, where many patients are insured by Medicaid (whose policies are set by individual states) or are uninsured, health care for transgender people is unlikely to center on these access issues because these services may not exist inside a public hospital or because there is no way to pay for them. There is a basic justice problem in the lack of access to gender-affirming therapies for younger, poorer transgender people, a problem that the public safety net, on its own, cannot fix. While it is of great importance that Medicare and some private insurers will now cover these therapies, it is strange to imagine telling a young, transgender person on Medicaid that he or she can transition at age sixty-five. But there are good reasons for safety-net institutions to focus on the most basic access issue—primary care. It is reasonable to conclude that the prevalent fear among LGBT people of being discriminated against by health care providers has led many of them to avoid seeking health care, that their preventive and routine health care needs (including sexual health) are unmet, and that they are living with medical and behavioral health conditions that could be resolved or managed through primary or other outpatient care.
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Improving Primary Care in the Public Safety Net: One Hospital’s Experience
M
etropolitan Hospital Center is a 338-bed facility in New York City’s public health system, the Health and Hospitals Corporation. Metropolitan serves Manhattan’s East Harlem community, with most patients self-identifying as being of Latino or African descent. Most patients who rely on Metropolitan are insured through public programs such as Medicaid and Medicare or are underinsured or uninsured. (A small percentage of Metropolitan’s patients, including hospital employees, have private insurance.) Undocumented immigrants, who are ineligible for most public benefits, are part of the uninsured population this hospital serves. Metropolitan provides an example of how even a financially strained safety-net hospital can improve primary care for the LGBT community. In 2010, Metropolitan’s executive director authorized the creation of an LGBT committee to support policy development aimed at improving care. Through the work of this committee, the hospital updated its visitation policy and patient rights statements to include nondiscrimination for the LGBT population, and it developed staff training in issues related to LGBT health care. The Human Rights Campaign, a national LGBT rights advocacy organization, offers an annual Healthcare Equality Index Survey to help health care organizations attain standards and improve LGBT health care, and in 2011 Metropolitan began participating in this survey.6 By 2013, the hospital was awarded leadership status by the HRC based on four criteria: patient nondiscrimination policies inclusive of sexual orientation and gender identity, equal visitation, employment nondiscrimination, and training on LGBT patient-centered care. Metropolitan became the first public hospital in New York City to achieve HRC leadership status. As part of its efforts to expand access to health care for LGBT patients and to improve health care for these patients, Metropolitan also surveyed patients in its behavioral health outpatient clinic to better understand patient perceptions concerning care needs for this population. The survey suggested that patients, whether or not they identified as LGBT, perceived a need for more services for the LGBT population. Based on these findings and the lack of LGBT-specific services in East Harlem or nearby neighborhoods, Metropolitan decided to establish its own LGBT clinic. As a public safety-net institution with a budget deficit, the hospital had no discretionary funds or other resources for this clinic; launching it would require creative use of existing staff and facilities. Research by the LGBT committee confirmed that a Saturday clinic would be of greatest benefit to the local community, as there were few Saturday appointments at the LGBT clinics in other parts of the city. The clinic opened on April 5, 2014. On the September-October 2014/ H A S T I N G S CE NTE R RE P O RT
We owe LGBT patients an investment in righting wrongs. first day, a cardiac problem was identified in one patient, while another was diagnosed as HIV positive. These patients subsequently received ongoing medical care through Metropolitan to help them manage their conditions. To date, community and patient feedback on these efforts has been supportive; several patients who have been diagnosed as HIV positive at the clinic told staff that, had this LGBTspecific clinic not existed, they would not have sought out care or testing elsewhere. Limits and Goals
T
his case illustrates the reality of what a public hospital can do for its LGBT community. Returning to the example of medical treatments associated with transition, a public hospital cannot provide medical services that are not offered within its system. Nationally, very few surgeons perform gender alignment surgery; this surgery is not provided in the Health and Hospitals Corporation system, which is the largest public hospital system in the United States. Metropolitan does not have specialists managing hormone therapy for transgendered patients, nor does this hospital offer feminizing or masculinizing procedures to the transgender population. This reality means it is unlikely that all medical services a transgender person needs can be provided within the public safety-net context; this is also the reality for low-income patients who are not transgender. Nevertheless, now that there are clear standards and benchmarks, from the Healthcare Equality Index Survey and The Joint Commission, to improve access to primary care for the LGBT community, the public safety net should embrace these goals in the interest of fairness and because they are consistent with the core mission of the safety net. Looking ahead, what else may justice require of our fragmented health care system to support moral progress in the safety net, including nonprofit as well as public institutions? It is clear from survey data that transgender people—in particular, low-income transgender people—face greater difficulties in securing access to health care than gay, lesbian, or bisexual people. This alone would be a good enough reason to focus on the “T” in LGBT health care, while aiming to improve health care for this population overall. There is another good reason. As Daphna Stroumsa points out in a comprehensive review essay on the “state of transgender health care,” the “unique” situation of a transgender person who may have “an undesired and unavoidable dependency on the medical system for basic identity expression” should be recognized as different from the situations of “sexual minorities (i.e., lesbians, gays, and bisexuals)” who may experience similar forms of discrimination.7
Familiar calls for “cultural sensitivity” do not capture the complexity of the relationship between transgender people and health care systems. Nor do such appeals, on their own, describe what share of limited resources a health care system owes to community members who are transgender, relative to obligations to other community members. A continuing challenge for health care organizational ethics, including specialty medical societies as well as care settings such as hospitals and community health centers involved in the care of transgender people, will be the familiar challenge of translating rights into resources. At present, good primary care in an inclusive environment is as far as a public hospital’s resources are likely to stretch. This is an important organizational goal, and a step toward justice, for a population with a history of avoiding health care based on fear of stigma and discrimination. In creating a safe, welcoming, and knowledgeable health care environment for LGBT people within severe resource constraints, focusing on primary care and the creation of trustworthy relationships with health care workers, the public safety-net institution can do its part for moral progress. Disclaimer
Stephan Davis is the director of nursing excellence and utilization management at Metropolitan Hospital Center in East Harlem, New York. The views expressed here are those of the authors; they do not necessarily reflect the views of Metropolitan Hospital Center. 1. HealthyPeople.gov., “Lesbian, Gay, Bisexual and Transgender Health,” U.S. Department of Health and Human Services, accessed July 24, 2014, at http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25. 2. Lambda Legal, “Transgender and Gender-Nonconforming People,” insert in When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination against LGBT People and People Living with HIV (New York: Lambda Legal, 2010), p. 1-4, at 1, accessed July 24, 2014, http://www.lambdalegal.org/publications/when-health-careisnt-caring. 3. Lambda Legal, “Executive Summary,” in When Health Care Isn’t Caring, p. 5-7, at 6. 4. Lambda Legal, “Low-Income or Uninsured LGBT People and People Living with HIV,” insert in When Health Care Isn’t Caring, p. 1-4, at 2. 5. The Joint Commission, “Effective Communication, Cultural Competence, and Patient-and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide,” 2011, accessed July 24, 2014, at http://www.jointcommission.org/lgbt/. 6. Human Rights Campaign, “Healthcare Equality Index 2013 Report,” accessed July 24, 2014, at www.hrc.org/hei. 7. D. Stroumsa, “The State of Transgender Health Care: Policy, Law, and Medical Frameworks,” American Journal of Public Health 104, no. 3 (2014): e31-38, at e31, e32.
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
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Moral Progress in the Public Safety Net: Access for Transgender and LGB Patients by Stephan Davis and Nancy Berlinger
A
s a population, people who self-identify as lesbian, gay, bisexual, or transgender face significant risks to health and difficulty in obtaining medical and behavioral health care, relative to the general public. Commonly cited risks include higher rates of homelessness and of suicide attempts among youth, of sexually transmitted infections and substance abuse, and of being the target of violence.1 Within this population, transgender people are far more likely to express concerns about how they will be treated when they seek health care. A survey conducted by Lambda Legal in 2009 found that, among nearly five thousand total respondents, “transgender or gender-nonconforming respondents reported experiencing the highest rates of discrimination and barriers to care.”2 This survey also found that LGBT people of color or with low incomes were more likely to experience “discriminatory and substandard care.”3 It is therefore not surprising that transgender people of color and transgender people who are low income experience extremely high rates of discrimination in health care. Over 80 percent of low-income or uninsured transgender respondents to the Lambda Legal survey felt that they would be treated “differently” from other patients when they sought health care; this was also a significant concern of higher-income transgender people (68 percent) and of greater concern to low-income gay, lesbian, or bisexual people (39 percent) than to higher-income gay, lesbian, or bisexual people (26 percent).4 These issues are especially challenging in safety-net health care institutions, which serve a range of vulnerable populations with limited access, limited options, and significant health disparities. Safety-net hospitals, particuStephan Davis and Nancy Berlinger, “Moral Progress in the Public Safety Net: Access for Transgender and LGB Patients,” LGBT Bioethics: Visibility, Disparities, and Dialogue, special report, Hastings Center Report 44, no. 5 (2014): S45-S47. DOI: 10.1002/hast.370
larly public hospitals with fewer resources than academic medical centers and other nonprofit hospitals that also serve as safety nets, are under immense financial pressures for multiple reasons. For one, the Affordable Care Act mandated reductions in payments to disproportionateshare hospitals, which serve large numbers of uninsured patients, yet there is no certainty that these reductions will be offset by the newly insured, especially in states that have refused the ACA’s Medicaid expansion. In addition, a consequence of the “two-midnight rule” of the Centers for Medicare and Medicaid Services, a policy that aims to limit hospital admissions to patients who require at least two nights of inpatient care, is that hospitals are assigning more patients to “observation” status at a lower Medicare reimbursement rate to avoid being financially penalized by Medicare auditors. Safety-net patients often have limited options for needed postdischarge care, putting them at high risk of readmission, which triggers other financial penalties. Public hospitals also have to invest in infrastructure to support patient care, regulatory compliance, and information technology upgrades with fewer resources than other hospitals. From the hardnosed perspective of service utilization, how much incentive do cash-strapped public hospitals have to invest in care for a population whose members may need medical services not covered by public insurers or who may be perceived as time-consuming to “manage” or as “difficult,” requiring more of the limited resource of staff time? The answer, historically, has been “very little.” However, with the introduction in 2011 of standards for LGBT inclusion by The Joint Commission, showing progress on LGBT health care has become a compliance issue for hospitals.5 And because the health care community itself has contributed to LGBT health disparities through prejudice, disrespect, or inadequate knowledge that have made it difficult for LGB and especially T peo-
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
S45
ple to seek care or to obtain the care they need, there is a moral case for allocating scarce resources to this population: we owe them some investment in righting wrongs that the health care system itself has produced. So, where to begin in the typical safety-net hospital or clinic? Beyond staff training, which is essential and for which good models now exist, what does justice demand from a service-utilization perspective? Given the range of health care services that an LGBT person in the safety net may need or want, how should we set priorities? And what can’t we promise to do for this member of our community? For example, the range of medical treatments that may be part of gender transition are not yet consistently described and reimbursed by insurers. Under an important May 2014 ruling, Medicare now covers transition-related medical care, including sex reassignment surgery and hormone therapy, and private insurers who do not already do so are likely to follow Medicare’s lead, as is common with other treatments. Whether insurers should pay for procedures characterized as “cosmetic” continues to be debated. For instance, a person transitioning from female to male may consider undergoing a chin implant to acquire a more masculine appearance. A male who is not transitioning may wish to have the same procedure for the same reason. It is hard to make the case that insurance should cover the procedure for one man, while the other man should pay out of pocket. But in the public safety net, where many patients are insured by Medicaid (whose policies are set by individual states) or are uninsured, health care for transgender people is unlikely to center on these access issues because these services may not exist inside a public hospital or because there is no way to pay for them. There is a basic justice problem in the lack of access to gender-affirming therapies for younger, poorer transgender people, a problem that the public safety net, on its own, cannot fix. While it is of great importance that Medicare and some private insurers will now cover these therapies, it is strange to imagine telling a young, transgender person on Medicaid that he or she can transition at age sixty-five. But there are good reasons for safety-net institutions to focus on the most basic access issue—primary care. It is reasonable to conclude that the prevalent fear among LGBT people of being discriminated against by health care providers has led many of them to avoid seeking health care, that their preventive and routine health care needs (including sexual health) are unmet, and that they are living with medical and behavioral health conditions that could be resolved or managed through primary or other outpatient care.
S46
Improving Primary Care in the Public Safety Net: One Hospital’s Experience
M
etropolitan Hospital Center is a 338-bed facility in New York City’s public health system, the Health and Hospitals Corporation. Metropolitan serves Manhattan’s East Harlem community, with most patients self-identifying as being of Latino or African descent. Most patients who rely on Metropolitan are insured through public programs such as Medicaid and Medicare or are underinsured or uninsured. (A small percentage of Metropolitan’s patients, including hospital employees, have private insurance.) Undocumented immigrants, who are ineligible for most public benefits, are part of the uninsured population this hospital serves. Metropolitan provides an example of how even a financially strained safety-net hospital can improve primary care for the LGBT community. In 2010, Metropolitan’s executive director authorized the creation of an LGBT committee to support policy development aimed at improving care. Through the work of this committee, the hospital updated its visitation policy and patient rights statements to include nondiscrimination for the LGBT population, and it developed staff training in issues related to LGBT health care. The Human Rights Campaign, a national LGBT rights advocacy organization, offers an annual Healthcare Equality Index Survey to help health care organizations attain standards and improve LGBT health care, and in 2011 Metropolitan began participating in this survey.6 By 2013, the hospital was awarded leadership status by the HRC based on four criteria: patient nondiscrimination policies inclusive of sexual orientation and gender identity, equal visitation, employment nondiscrimination, and training on LGBT patient-centered care. Metropolitan became the first public hospital in New York City to achieve HRC leadership status. As part of its efforts to expand access to health care for LGBT patients and to improve health care for these patients, Metropolitan also surveyed patients in its behavioral health outpatient clinic to better understand patient perceptions concerning care needs for this population. The survey suggested that patients, whether or not they identified as LGBT, perceived a need for more services for the LGBT population. Based on these findings and the lack of LGBT-specific services in East Harlem or nearby neighborhoods, Metropolitan decided to establish its own LGBT clinic. As a public safety-net institution with a budget deficit, the hospital had no discretionary funds or other resources for this clinic; launching it would require creative use of existing staff and facilities. Research by the LGBT committee confirmed that a Saturday clinic would be of greatest benefit to the local community, as there were few Saturday appointments at the LGBT clinics in other parts of the city. The clinic opened on April 5, 2014. On the September-October 2014/ H A S T I N G S CE NTE R RE P O RT
We owe LGBT patients an investment in righting wrongs. first day, a cardiac problem was identified in one patient, while another was diagnosed as HIV positive. These patients subsequently received ongoing medical care through Metropolitan to help them manage their conditions. To date, community and patient feedback on these efforts has been supportive; several patients who have been diagnosed as HIV positive at the clinic told staff that, had this LGBTspecific clinic not existed, they would not have sought out care or testing elsewhere. Limits and Goals
T
his case illustrates the reality of what a public hospital can do for its LGBT community. Returning to the example of medical treatments associated with transition, a public hospital cannot provide medical services that are not offered within its system. Nationally, very few surgeons perform gender alignment surgery; this surgery is not provided in the Health and Hospitals Corporation system, which is the largest public hospital system in the United States. Metropolitan does not have specialists managing hormone therapy for transgendered patients, nor does this hospital offer feminizing or masculinizing procedures to the transgender population. This reality means it is unlikely that all medical services a transgender person needs can be provided within the public safety-net context; this is also the reality for low-income patients who are not transgender. Nevertheless, now that there are clear standards and benchmarks, from the Healthcare Equality Index Survey and The Joint Commission, to improve access to primary care for the LGBT community, the public safety net should embrace these goals in the interest of fairness and because they are consistent with the core mission of the safety net. Looking ahead, what else may justice require of our fragmented health care system to support moral progress in the safety net, including nonprofit as well as public institutions? It is clear from survey data that transgender people—in particular, low-income transgender people—face greater difficulties in securing access to health care than gay, lesbian, or bisexual people. This alone would be a good enough reason to focus on the “T” in LGBT health care, while aiming to improve health care for this population overall. There is another good reason. As Daphna Stroumsa points out in a comprehensive review essay on the “state of transgender health care,” the “unique” situation of a transgender person who may have “an undesired and unavoidable dependency on the medical system for basic identity expression” should be recognized as different from the situations of “sexual minorities (i.e., lesbians, gays, and bisexuals)” who may experience similar forms of discrimination.7
Familiar calls for “cultural sensitivity” do not capture the complexity of the relationship between transgender people and health care systems. Nor do such appeals, on their own, describe what share of limited resources a health care system owes to community members who are transgender, relative to obligations to other community members. A continuing challenge for health care organizational ethics, including specialty medical societies as well as care settings such as hospitals and community health centers involved in the care of transgender people, will be the familiar challenge of translating rights into resources. At present, good primary care in an inclusive environment is as far as a public hospital’s resources are likely to stretch. This is an important organizational goal, and a step toward justice, for a population with a history of avoiding health care based on fear of stigma and discrimination. In creating a safe, welcoming, and knowledgeable health care environment for LGBT people within severe resource constraints, focusing on primary care and the creation of trustworthy relationships with health care workers, the public safety-net institution can do its part for moral progress. Disclaimer
Stephan Davis is the director of nursing excellence and utilization management at Metropolitan Hospital Center in East Harlem, New York. The views expressed here are those of the authors; they do not necessarily reflect the views of Metropolitan Hospital Center. 1. HealthyPeople.gov., “Lesbian, Gay, Bisexual and Transgender Health,” U.S. Department of Health and Human Services, accessed July 24, 2014, at http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25. 2. Lambda Legal, “Transgender and Gender-Nonconforming People,” insert in When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination against LGBT People and People Living with HIV (New York: Lambda Legal, 2010), p. 1-4, at 1, accessed July 24, 2014, http://www.lambdalegal.org/publications/when-health-careisnt-caring. 3. Lambda Legal, “Executive Summary,” in When Health Care Isn’t Caring, p. 5-7, at 6. 4. Lambda Legal, “Low-Income or Uninsured LGBT People and People Living with HIV,” insert in When Health Care Isn’t Caring, p. 1-4, at 2. 5. The Joint Commission, “Effective Communication, Cultural Competence, and Patient-and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide,” 2011, accessed July 24, 2014, at http://www.jointcommission.org/lgbt/. 6. Human Rights Campaign, “Healthcare Equality Index 2013 Report,” accessed July 24, 2014, at www.hrc.org/hei. 7. D. Stroumsa, “The State of Transgender Health Care: Policy, Law, and Medical Frameworks,” American Journal of Public Health 104, no. 3 (2014): e31-38, at e31, e32.
SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e
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