Affordable Care Act rules arrive to combat health care discrimination in Memphis

Aug. 06--Mickey Fuller praises her primary care doctor, but as a transgender woman in Memphis, she's found challenges and sometimes hostility while seeking health care.

After three months, the first endocrinologist overseeing her hormone replacement therapy "told me that he was not comfortable treating someone like me," said Fuller, 46.

Since last September, she's had no success lining up a hospital and urologist covered by her health insurance to perform a key transgender surgery. One hospital denied use of its facilities on religious grounds, she said.

"People are just, you know, especially around here, this being the Bible Belt, people have their own preconceived notions about transgender people," she said.

The issue of discrimination and civil rights in health care for transgender people nationwide, among other protected groups, quietly took a historic step in July.

Six years after its passage, the Affordable Care Act is giving physician practices, hospitals, health insurers and others receiving federal funds new guidelines prohibiting sex discrimination. That includes gender identity, gender stereotyping and pregnancy.

A provision of the health care reform law known as "Section 1557" provided protections based on sex, race, color, national origin, age or disability.

While the protections took effect with the Affordable Care Act in 2010, U.S. Department of Health and Human Services final rules were published in May and took effect July 18, said David Thornton, a health care and employee benefits attorney with Bass, Berry & Sims in Memphis.

"In all likelihood, it may not change how medical providers treat anyone, but now it's providing basically a federal civil rights law that prohibits a physician practice, or a hospital, or a health insurer who received federal funds from discriminating on the basis of gender, race, color, national origin, gender identity and so forth," Thornton said.

It also requires increasing health care access to people with limited English-speaking skills and to people with disabilities.

Estela Ramirez, 39, speaks Spanish and said it was difficult to understand her care and convey her feelings during three weeks in Memphis hospitals. She needed a stem cell transplant because her body stopped producing enough new blood cells.

Ramirez preferred the in-person interpreters available through Methodist Le Bonheur Health Care to the interpreter telephone line provided by Baptist Memorial Healthcare.

"I couldn't understand what the doctor was saying," she said. "I only understood some of the side effects, but not everything. I couldn't ask him any questions or concerns.

"At times, it can be frustrating not being able to tell him how I was feeling," Ramirez said. "I thank God nothing serious happened to me."

Methodist can offer in-person interpreters, live video and a phone service; Baptist offers a service called Language Line available all hours that is compliant with Section 1557, spokespersons said.

More than 25 years since passage of the Americans with Disabilities Act, issues such as accessible examination tables or restrooms in a physician's office may crop up, said Tim Wheat, program director for the Memphis Center for Independent Living.

Yet, in Memphis and statewide, the biggest obstacle to health care access for people with disabilities is the state's refusal to accept Medicaid expansion dollars that the Affordable Care Act offers, Wheat said.

Gov. Bill Haslam's Insure Tennesse plan would cover an estimated 200,000 low-income people who don't qualify for federally subsidized coverage through the HealthCare.gov insurance market place. The state's Republican-controlled legislature has rejected the governor's plan.

"Often it's people who need preventive care, need basic things to help them live healthy, so they don't get more chronic problems, bedsores, different things like that," Wheat said.

For health care providers, the new regulations will require new steps, Thornton said.

Among them: Naming a compliance coordinator to train workers about the law, notices in various languages informing patients of their rights, and adopting a grievance procedure for complaints. Employee benefits may be affected.

The state's largest insurer, BlueCross BlueShield of Tennessee, added gender reassignment coverage this year for fully insured intermediate and large-group customers and will add it beginning in January for small-group and individual insurance, officials said.

Health care discrimination complaints can be filed with the HHS Office of Civil Rights.

"It also created private right of actions where an individual could actually bring a lawsuit alleging violation of this law and seeking damages," Thornton said.

He said gender identity issues are likely to draw the most attention.

The Memphis Gay and Lesbian Community Center maintains a list of doctors who have received good reviews, said Will Batts, executive director for the center.

"I know that it's not just the transgender community, but the whole LGBT community," Batts said.

"Certainly lots of stories about people not feeling comfortable coming out to their physicians because of how they may be treated, especially transgender patients who find quite often that their physicians don't know enough about what transgender means to effectively deal with the issues that they bring up," he said.

Fuller said she's had that experience finding a new endocrinologist, but overcame it by transferring to a more knowledgeable doctor.

Born a boy named Carl and nicknamed Mickey, Fuller said one of her earliest memories was lying in bed and praying that God would change him into a girl during the night.

A motorcycle crash in 1996 left her with dozens of fractures and on disability assistance, which she continues on today, she said. Her landlady died in 2012 meaning to leave her the Midtown house where she lived, but it ended up a in foreclosure and Fuller said she's living there basically as a squatter.

The inflammation that causes her rheumatoid arthritis landed Fuller in a hospital with a heart problem in 2013, she said. It was then that she decided she wanted to spend however many days she has left happy as a transgender woman.

After her first hormone therapy shot, she said she woke up happy, with a life-long depression lifted.

Fuller laughed at the idea that the Affordable Care Act's protections against discrimination will solve her challenges health care.

"I think it's going to take a couple of lawsuits and going probably up to the United States Supreme Court to get a decision," she said.

Commercial Appeal reporter Maria Zamudio contributed to this story.

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