Community Legal Aid SoCal’s (CLA SoCal)  Health Consumer Action Center (Health Unit) has long been aware that transgender individuals in Orange County face many barriers to accessing medically necessary care. In practice, if an individual is diagnosed with a new health condition, their doctor would provide a treatment plan, which the health plan timely approves, and then the condition is effectively treated. However, that is not the case for transgender individuals.

Regardless of the type of health coverage, accessing gender affirming care has been a struggle for transgender individuals. Patients have to appeal denials, which causes delays and continued pain, and forces them to justify why the care they seek is medically necessary. In addition to dealing with a health condition, transgender individuals experience stress, exhaustion, and anxiety trying to navigate the system to get the care they need.

Barriers and delays

Even if a referral to another doctor is approved, there are few or no in-network specialists, let alone those who have experience treating transgender individuals. If no in-network provider is available, then an out-of-network provider needs to be found, which means more paperwork, more delays and often travel to Los Angeles to receive treatment there.

There is one clinic in Los Angeles that has been contacted by about 100 Orange County Medi-Cal patients to access services. Travel causes its own complications, and the Health Unit has one client who waited several hours after a procedure for the medical transportation to pick her up.

If the specialist recommends surgery, it requires another request to the health plan and, likely, another appeal after the health plan denies the request. Even if the surgery is approved, it often is not the end of the delays and barriers.

For one of the Health Unit clients, the surgery was approved but at a Catholic hospital. The hospital canceled the surgery at the last minute and refused to perform it on claimed “ethical” grounds. It took the health plan four months and the intervention of a Health Unit attorney before the surgery finally took place at a different facility.

Identifying systemic issues

The Health Unit has represented individual transgender clients facing these barriers and has successfully appealed denials and expedited treatment. But the more they learned about issues facing the transgender community in Orange County, the more they saw the systemic problems. The biggest—and most basic—of which was that the health plans lacked a basic understanding of the needs of the transgender community.

To start working on the systemic issues, the Health Unit first met with CalOptima in December of 2019 to discuss potential collaborative solutions. Through the relationship they built with CalOptima leadership, they were asked to present a training to about 200 CalOptima staff earlier this year regarding gender identity and suggestions on improving gender-affirming care.

Supporting change

A CLA SoCal Systemic Impact Unit (SIU) attorney participated in the presentation, as SIU had been collaborating with the Health Unit on a case of a transgender client who was denied care. Through their work, SIU talked to various community members and medical providers who had experience providing gender affirming care and brought in an advocate and program coordinator from the UCI Gender Diversity Program to participate in the presentation. A transgender individual themself, their role at UCI is to help transgender individuals understand, navigate and advocate for medical treatment.

The presentation was a great success and received enthusiastic feedback and with a request for use of CLA SoCal’s PowerPoint presentation and other resources. As Health Unit supervising attorney Sara Lee shared, “During our presentation, CalOptima’s attendees were engaged. Attendees, comprised of directors and staff from various departments, including member services and the department in charge of approving and processing claims, were listening carefully and asked a lot of questions. They clearly wanted to understand issues like the importance of gender pronouns, when to use them, and how to ask patients about the pronouns they use.”