In the spring of 2016, Elijah Fischer called his insurance company to ask if his plan would cover a double mastectomy. A 27-year old Floridian and trans man, Elijah had mostly completed his gender transition, except he still had feminine breasts.



“I look down, and it’s not me,” Elijah recalled feeling. He felt foreign to himself. With summer approaching, he dreaded another season of avoiding the beach and kayaking with his wife, Brianna.

So it was a relief when his insurer, Anthem Blue Cross Blue Shield, approved the surgery right away.

“Oh wow,” the couple said to each other, Brianna recalled. “That was easy. That was fantastic.”

In reality, it was just the start of a battle with Anthem that would stretch for more than nine months. The company backtracked, and revealed that Elijah’s policy specifically excluded “services and supplies related to sex transformation”. There were fraught phone calls and fine print before finally, Elijah contacted the Department of Health and Human Services (HHS) about filing a discrimination claim.

His case, he felt, was clear-cut. There is a federal law that bans insurers from discriminating against someone on the basis of gender. In practice, the government has said, this means an insurance company cannot cover a therapy or a procedure in one situation but refuse when the patient is trans. For example, since Eljiah’s Anthem plan covers mastectomies for women in many cases, the carrier ought to cover the same surgery for Elijah.

But that interpretation of the law came from the Obama administration. And the law banning gender discrimination in healthcare is the Affordable Care Act (ACA), President Trump’s number-one target as he seeks to dismantle his predecessor’s legacy.

Elijah’s story offers a glimpse of the hurdles that may face trans people if Republicans succeed in repealing the ACA. The nondiscrimination rule might be at special risk now that a repeal effort has failed in Congress and the Trump administration is exploring ways to undermine Obamacare by failing at enforcement.

Some insurance companies seem already to be counting on it. A few weeks after Trump’s election, a civil rights investigator with HHS called Elijah with bad news. His insurance still had not agreed to cover his surgery and on top of that, insurance carriers around the country were scrapping their plans to comply with Obama’s rule for trans healthcare, while they waited to see what would happen to the ACA.

“I didn’t want to go another another year waiting,” Elijah said. “Let alone four.”

And so, on the morning of 7 March, the Fischers drove four and a half hours south to Fort Lauderdale and checked into a hotel near the surgeon’s office. They had decided to pay for Elijah’s operation themselves, at a cost of almost $10,000.

Out-of-body, out-of-pocket

The roadblocks Elijah faced are exactly the kind the Obama administration set out to eliminate.

Trans people, studies have found, are extremely vulnerable to the whims of the healthcare market. A 2015 poll of more than 27,000 transgender adults found that in the preceding year, 55% who sought insurance coverage for transition-related surgery were denied.

There is no data that compares that rate to the share of non-trans people who are denied coverage for surgery. “But my educated guess is this happens to trans people much more often,” said Ezra Young, a litigation director for the Transgender Legal Defense and Education Fund.

The reasons are sometimes mundane. While some insurance carriers specifically exclude coverage for transition-related healthcare, other insurers simply lack guidelines for determining when transition care is covered. As the Obama administration was finalizing its rule, some insurers complained that their computer systems wouldn’t allow them to approve a female surgery, such as a hysterectomy, for a male client.

Mainstream medical experts consider it imperative for transgender people to have access to sex reassignment surgery. In 2008, the American Medical Association called on insurers to stop placing limitations on procedures such as breast removal, calling sex reassignment therapy a medical necessity for many trans people.

“It’s anxiety,” Elijah said recently, describing the strain he felt whenever he looked at his chest. “It’s almost like having an out-of-body experience. It’s not being able to identify with a part of me.”

Anthem set the Fischers on a merry-go-round, Brianna said. The insurer would tell Elijah it would cover his surgery. But when his surgeon’s office asked Anthem the same question, the insurer would say the opposite. And on and on.

Meanwhile, Elijah’s one-on-one interactions with Anthem were becoming unbearable. A customer service agent asked repeatedly if he was seeking a vasectomy instead of a mastectomy, he said. Another call turned into an interrogation.

“That was a bad phone conversation,” Elijah said. “He just kept grilling me on why I needed a female procedure if I was male.” Elijah tried to explain that he was transgender, but eventually, Elijah hung up.

In June, he started pursuing a civil rights complaint with the health department.

Elijah provided a copy of his 2016 insurance policy to the Guardian, which shared it with Young at the Transgender Legal Defense and Education Fund. Young said that, barring any riders, the policy appeared to be discriminatory against trans people. It had a specific provision that excluded all “services and supplies related to sex transformation”.

Elijah also provided the Guardian with emails between himself, Anthem, his surgeon’s office and an investigator assigned to him by the HHS office of civil rights. All his emails strike a similar tone: polite but firm, detailed but in a hurry.

In the fall, Elijah and Brianna were getting married. They pictured a large reception with dozens of friends and family members, and Elijah in a tuxedo, looking, at last, like himself.

“Seeing pictures of our wedding and knowing my chest was still there, I didn’t want that,” he said. The thought of it – “that I’m not going to get to look at those pictures the way I wanted to, and see the real me” – made him furious.

By August, it began dawning on the Fischers that Anthem might never agree to cover his surgery, much less in time for their wedding day. So they let go of their plans for a big celebration. When guests asked what they wanted as gifts, they said they wanted money to pay for Elijah’s surgery. They needed more than $5,600 for the procedure and another $1,000 for the anesthesiologist. Several thousand more would go towards food, a hotel until Elijah had recovered enough to make the drive home, and a mountain of medical supplies.

They celebrated their marriage in October, with Elijah’s tuxedo hiding the binder he wears to conceal his chest.

Then, on 13 December, the civil rights investigator sent an urgent email: “Please call me now.”

According to Elijah, the investigator, Beatriz Romero-Escobar, said she was hearing from trans clients everywhere who were being denied procedures that were supposed to be covered beginning in 2017. She did not respond to a request to speak for this story.

“She said, ‘It sounds like, because Trump is taking office, they’re waiting to see what happens … Because he wants to repeal the Affordable Care Act,’” Elijah said.

Anthem had once told him, over the phone, that it was changing its policies to cover trans procedures in January 2017. But the insurer was ignoring entreaties to provide its assurances in writing. That’s when the Fischers made the decision to pay for Elijah’s surgery out of pocket.

Elijah’s surgery took place in early March. The first time he saw himself in the mirror, he cried out of happiness.

In response to the Guardian’s questions, Anthem said it had in fact removed the transgender exclusions in Elijah’s plan on 1 January. Provided Elijah meets certain qualifications, when he submits a surgery claim he should receive reimbursement.

If not, the Fischers are bracing for a time of financial hardship. They do, however, plan to put some money aside for this October. Brianna still has her wedding gown. Elijah still has his tuxedo. They’re hanging in the couple’s closet, Elijah said, until their first anniversary, when he and Brianna will take the photos they had wanted.