Transgender patients are among the most marginalized populations that interact with the healthcare system.
A 2018 study, for example, found that 70% of transgender patients experience discrimination when they seek out care, and that led nearly half (43.8%) to avoid the emergency department when they needed acute care. A 2017 poll found that 31% of trans patients lack regular access to healthcare.
In an effort to make a dent in those trends, Blue Cross and Blue Shield of Minnesota launched its Gender Care and Service initiative in 2016. In May, the insurer brought on Alex Jackson Nelson to serve as its first gender services consultant. Nelson works directly with members to assist them in navigating their care needs.
Nelson, who is transgender himself, told Fierce Healthcare that he aims to see his role and the program grow to address health inequities in an intersectional way that extends beyond gender identity. Trans people of color, for example, experience substantial barriers in accessing care beyond what white trans people might experience, he said.
“I’m just starting to think, ‘Wouldn’t it be amazing if this movement really moved across identities?’ and it’s not just ‘this is the transgender’ program, but 'this is a health equity program,'” he said. “When we take care of each other, we’re all taken care of.”
Here’s more from our conversation:
Fierce Healthcare: Tell us more about the work you’re doing and your role at Blue Cross.
Alex Jackson Nelson: Blue Cross started this work in 2016. It was an initiative to understand barriers to health experiences by transgender and nonbinary folks, and then based on those experiences to help create and implement solutions. So, the work really started through asking community members—and this was before my time there—“What are the barriers to care?”
And then finding and getting all these answers and bringing those answers back to kind of make some systems changes and shifts at Blue Cross. And that’s how many of the system's changes were made. Then Blue Cross decided that they needed to get their own policies worked out so that they were equitable in terms of trans care, and employee policies related to trans folks coming out at work and gender-neutral bathrooms and locker rooms.
So they did all sorts of their own internal work before they started to do the external work of responding to community members who said, “These are the barriers.” They also talked with a lot of stakeholder providers about what some of the barriers were for them when they’re doing insurance billing and things like that, too.
A part of that work was the creation of my position.
FH: What are some of the challenges and barriers that transgender and nonbinary patients may run into when trying to navigate the healthcare system?
AJN: When I think about the things that are in the way, the systems are just in the way because so many times the systems are binary gendered. So, if there’s no other option than male. In insurance, claims will get denied or bounced back. I’m a trans person. I’m a trans guy. So if I get pap smear and my insurance card says “male,” how does the system handle that? And oftentimes it ends up coming back to the consumer, to the patient, to have to negotiate those things.
So, I think that’s a broader barrier across systems, that the systems are just not ambiguous enough.
And then there’s a lack of care and community, or I should say, lack of respectful care for trans folks. So, trying to uplift providers who are doing really good work in the trans community and trying to get more providers interested in that work so there are more options for the trans community to see different practitioners is part of our goal, too.
FH: You have a diverse background of work before joining Blue Cross. Why was working with a health insurance company attractive to you?
AJN: I did some consulting for Blue Cross, doing training and some other consulting work for them around this initiative when it started. I’ve been doing consulting for a couple years with them as a trainer, and was training some of their nurses and case management and customer service staff on how to respectfully work with trans folks when they’re mostly talking with them on the phone.
And I really, really was struck by the culture. I was in conversations in the Twin Cities—in rural Minnesota they have an office—and in all of my conversations I was just struck by the culture of the organization and how willing people were to be in conversations not just around transness or queer identifies, but also race and class and all sorts of other things, and the way they were talking about the importance of healthcare for all communities and the importance of access to healthcare for all communities.
So, I think that was super helpful for me in applying for this job, because I was a little wary of big business. Blue Cross is a nonprofit, but it’s a big nonprofit. So, I got a taste of what the culture was there which made me then more curious about this position.
And my skill set fits perfectly. Like I said, I’m a trans person and have totally struggled with getting my own healthcare needs met. I came out over 20 years ago so the landscape was different then, but it’s not better as it should have been from back then. It hasn’t changed that much, and it’s been 20 years, in terms of healthcare and insurance.
So, I had struggled and still do struggle with my own medical needs and insurance needs. I worked case management and therapy for trans mostly youth and adolescents, and lots of those folks were 18, 19, 20, 21. And again, battling insurance companies so they could get their needs met around gender care was always a constant when I was a therapist and case manager. Trying to help people navigate those systems is something I was doing anyway, so this seemed like a good fit for me to use some of those experiences to try to not just help members because I’m really excited about that direct service component. I’m talking to members and trying to help them understand their plans and navigating the systems.
But also, I really like macro-level work. The executive sponsor of this position is the CEO of the company, and that brings me a level of trust that this position is not just going to be serving members but also taking the experiences of members and bringing that in to shift policy internally and hopefully be a model for other companies. I believe that’s going to happen, and that made me excited.
I get really excited about direct service with members and every day being able to say I helped somebody out, and then I get really jazzed about thinking about using those experiences—because they’re not all going to be good experiences—to try to change policy to make it better for everybody.
FH: What are some specific things you hope to accomplish in this role?
AJN: What I would like to see happen, and I don’t know if I can impact this, but I was just on a call today talking about what is our impact on federal policy and federal insurance plans. I think it would be amazing to see all insurance providers have a medical policy like we do, and I didn’t know that before I started at Blue Cross, I didn’t know what the medical policy was. But it’s incredible, it follows best practice internationally it’s just incredible policy compared to 20 years ago.
Wouldn’t it be amazing if, with that medical policy and this position, if other insurance companies would follow suit in understanding how marginalized trans folks are inside of mental health and medical health systems and the insurance piece? That would be amazing. I’d love to see other companies take this on and do the same things for this population of people.
It feels successful to me when I make a call to a member and they’re just like in awe that I’m calling them and that I care about them not getting the runaround, and that I’m able to say, “Hey, can I help explain this policy to you so you can fully understand it? And go line-by-line so you understand it using trans-competent language” and things like that. So far, I’ve talked to maybe a dozen people, and they’ve all just been blown away. So that feels amazing.
I don't know how many members I'll talk to this year, but if I’m impacting a couple hundred people and they’re able to understand their policy and get their needs met and not feel like the universe is against them in one area of their life, that feels pretty amazing to me.