Healthcare consumers from a variety of personal backgrounds regularly encounter challenges moving through the U.S. healthcare system, and need assistance, especially as they navigate some of the complexities around health insurance coverage for patient care of a variety of types. Among the subgroups sometimes needing an extra level of facilitation are individuals who are transgender or gender-non-binary. As those individuals move through passages and changes in their lives, often, the gender-binary nature of patient care documentation and classification becomes problematic. For example, a transman who began life in a female body but transitioned to male identity, will still need to undergo pap smears through a large part of his life. Similarly, a transwoman who began life male but lives as a female, will still need to receive PSA tests. And both individuals will face the challenges embedded in electronic health records (EHRs), which classify the gender of every patient in a binary, exclusive way.
But progressive health plan leaders are beginning to move forward to recognize the challenges facing their trans and non-binary members, and to change the landscape of their navigation of plan member processes. One of those health plans is the Eagan-based Blue Cross and Blue Shield of Minnesota (BCBSMN), where president and CEO Craig Samitt, M.D. has stated very publicly his commitment to fairly serving all of the health plan’s members, whether they are members of color or LGBTQ (lesbian, gay, bisexual, transgender, queer) members. In that context, BCBSMN’s leaders four years ago created a Gender Care Services Initiative, and in May, it advanced further, hiring an LCSW-licensed social worker and transman, Alex Jackson Nelson, as its first gender services consultant, coordinating the support for trans and non-binary members, as they navigate plan processes.
Dr. Samitt is committed to viewing all the issues involved through the lens of social justice. “Let me start at 40,000 feet,” he explains, with regard to the creation of the Gender Care Services Initiative. “We believe we were ahead of our time, pre-COVID and the current discussion on racial injustice, and we had already looked at the financing and healthcare delivery gaps in the healthcare system, and our strategic plan that we completed two years ago was around re-envisioning healthcare. Making sure that every Minnesotan had access to equitable, affordable, high-quality healthcare, we decided our strategy would be to really look at the challenges in our industry and to really try to fix them. That motivated us to be different; we weren’t going to be taking the existing assumptions. We represented it to our board, completed our five-year strategic plan eleven months ago. And the focus was delivering on the promise of the Quadruple Aim, with the idea that affordable, high-quality healthcare with a good experience and making it a good place to work in healthcare, was possible.”
In that context, Samitt says, “Frankly, what that looks like, is a culture of non-discrimination. We want an environment where all of our colleagues can come to work comfortably, regardless of their race, gender, sexual orientation, or any other element. So we’re feeling and seeing the decades-long, if not centuries-long failure to address some of these social inequities, that tie into healthcare delivery. And we focused in on the LGBTQ community in particular, because there are some inequities that particularly affect transgender and non-binary members. This is what happened when I got here in 2016—we came to the commitment to examine barriers to access and good care. And even beyond the LGBTQ community, when you think about racial inequities—imagine a world in which your health plan advocates for you. And so for the transgender and non-binary community, we looked at the obstacles and challenges that that community faces and that are not challenges that the broader community normally faces. So in many cases, we needed a new support paradigm to help walk that community to a comparable outcome as others see. And culturally, because of our very outspoken and overt desire to have a truly equitable environment in our workplace and in our community.”
Speaking of the creation of his position and of his department, Jackson Nelson reports that “Before my position was created, in early 2016, BCBSMN had started its Gender Care Services Initiative. That initiative was intended to understand the barriers to good experiences by transgender and non-binary health plan members. That’s when the initiative began, and my position grew out of that initiative. I started in May, two months ago.”
So far, Jackson Nelson is the first hire on the team, and he is housed with the care management team. Speaking both as a licensed social worker and a member of the LGBTQ community, Jackson Nelson says, “I’m transgender myself, and have experienced my own frustrations in advocating for myself in health insurance, and have worked in the queer community with transgender youth for nearly 20 years, as a therapist and as a case manager. Before I came to Blue Cross Blue Shield of Minnesota, I worked in the Department of Health and Human Services for the state of Minnesota, and also for a small non-profit called Reclaim, which works with LGBTQ youth, but specifically focuses on serving transgender youth of color. I did therapy there for a little over a year, but supported the founding of the organization for various ways, so have been involved with it for a long time.”
It is in that context, Jackson Nelson says, that he came into contact with Blue Cross Blue Shield of Minnesota, through that community-focused work. “Blue Cross began back in 2016 doing a lot of work with the community, assessing the needs of transgender and gender non-binary community members and of providers to the community; and they worked with providers, including the University of Minnesota Health System. Blue Cross went out and asked the transgender and non-binary community and providers, what the barriers were in accessing services and navigating the system. There are lots of national stats known nationwide on challenges facing transpeople. So that was the reason to create the position.”
Speaking of the challenges that he is helping members to overcome, Jackson Nelson notes that “There are a lot of systemic barriers. First, there’s a lack of qualified and culturally competent providers; so that’s a challenge. Just the way that systems function, in terms of having binary gender options, such as in the EHR—and all of the systems in the way they communicate. So if I as a transman—if I were to go get an annual exam or a pap smear, sometimes, the insurance company would bounce that back and say, why is this guy getting a pap smear? The same with a PSA test for a transwoman. And the other big piece is the complexity of gender health services, including transitioning services such as surgery, being covered in the system. BCBSMN has an amazing gender transition surgery, one of the best I’ve seen; but it doesn’t always matter if their medical policy is amazing, because if the employer chooses what to include in their benefits, or if they’re self-insured, that can still create a barrier. So my role is to help members navigate through those system challenges, as well as helping them find the right doctors and the right care.” And, he adds, “Providers struggle to navigate the system as well.”
Further, Jackson Nelson notes that, beyond the problems encountered with binary gender designation in the context of clinical documentation, and the challenges around health plan approval of certain types of services to transgender and gender non-binary members, “What feels important to me in my position here is understanding the possible trauma that healthcare systems have caused transpeople. So if my insurance claim gets bounced back over a pap smear, that leads to frustration, but it can be compounded by being treated poorly as a transperson; and then people of color, especially trans African-American women, for example, have less access to care in particular. So binary gender designation is a problem, but part of a broader problem. For example, we send a welcome letter to new members, but that’s auto-generated by the name that’s on their insurance card. And that person might already have spoken with me. And so then the system auto-generates a letter that is theoretically from me, but uses their former name. It’s about those tiny microaggressions; that’s the kind of thing we’re working on here.”
Support from senior management seen as fundamental
One of the most important elements in doing this work, Jackson Nelson says, is obtaining and maintaining support from executive management in one’s health plan. And in that regard, speaking of BCBSMN’s senior executives, that support “has been amazing, extraordinary. The executive sponsor of this position is the CEO, Dr. Samitt. And that’s been a huge deal for me in accepting the position. And the folks I’ve talked to are so excited to have me; I’ve felt very welcomed. And I think they’re so excited because they know that these systems are difficult to change, and so I add a friendly voice on behalf of the community. And so people are very excited to have me, which is awesome.”
What will the next year be like in his work? “The next year will really be focused on external member experiences,” Jackson Nelson says. “A part of it is working with providers. Ani Koch really started to drive the gender care and services initiative; they are senior program manager in the community health and health equity division. They are non-binary. What they recognized is—and this goes back to a question you asked earlier about how members are being funneled into me. We have a new website now, so the members I’m getting are seeing the website and contacting me directly. Previously, lots of members were going to Ani for support. So even though they’re positioned to work with members, they were positioned to work with members before I came, and to work with attorneys and healthcare workers. So they were a person who was helping members who were struggling. I mentioned Ani because they had worked for years on the internal pieces of making Blue Cross Blue Shield a trans-friendly place for employees and on the organization’s medical policy, before I was hired. And they realized they needed then to focus on member experiences. So that’s why I’ll be focused on that area.”
Have there been any challenges along the way? They’re at a high level, Samitt says. “The challenges are often that we tend to be a paternalistic industry—that we who don’t have a lived experience, design solutions to problems that we’ve never struggled with. We can’t be paternalistic; we can’t presume to know the answers. We have to listen and understand, and frankly, have those with the lived experience, create the solution. And that’s what we’re most proud of,” he notes. “The creation of the gender services consultant position was created not by executives, but by teammates.”
Samitt also says that there was no need to do research to determine whether other health plans had created this kind of service before or not. “When you look at other industries, you find that when you follow any mold, you tend not to be innovative,” he says. “So when you look at disruptors, they don’t follow molds. Uber didn’t start with what Yellow Cab was doing. It’s important to address the heart and soul of the problems and needs of customers. We tend not to take that approach.” What’s more, he notes, the healthcare industry has tended to be very paternalistic in the past in terms of how it treated patients/health plan members. Going forward, he says, “We need to stop trying to create the future by looking to the past; instead, we need to look at what was considered impossible, and make it possible.”