Last year the TGI Inclusive Care Act went into effect. Senate Bill 923 aims to protect the right of Transgender, Gender Diverse, and Intersex (TGI) Californians’ access to gender-affirming care by implementing quality standards and a training curriculum informed by the needs of the TGI community. To help accomplish this, the California Health and Human Services Agency created the TGI Working Group, consisting of state Department representatives, health care providers, TGI individuals, and TGI-serving organizations. The Working Group released its final report, which includes recommendations and highlights the importance of including the voices of people across the TGI community when developing new standards and training programs. The state is slated to issue guidance based on the final report by September 1, 2024 and health plans and insurers will have six months to implement the cultural competency training requirement of the bill.
TGI health care access has been a critical area of unmet need for a long time. Now that the state has released the final report, the state departments involved have a more defined path to ensure health plans and insurers are providing quality, inclusive care to their TGI enrollees.
Recommendations for a TGI Training Curriculum
The TGI Inclusive Care Act requires health plans and insurers to provide cultural competency training to staff who directly interact with TGI enrollees. The Working Group developed recommendations for an evidence-based training curriculum for health plans. The goal of the curriculum is to teach staff how to administer trans-inclusive, comprehensive care that “honors an individual’s gender, accepts gender fluidity and nontraditional gender presentation, and treats everyone with compassion, understanding, and respect.”
As the Working Group’s final report makes clear, it is essential that people of all lived experiences and identities within the TGI community are involved in informing the mandates of the Act, including training health plan and insurer staff using the recommended curriculum. Cultural competency training is complex and must take into account that all communities are diverse. It’s important that the training requirement is approached with intersectionality at the forefront.
With health equity for TGI individuals being the primary goal of the Act, the inclusion of different voices—from Black, Indigenous, and People of Color (BIPOC); Non-binary and Intersex individuals; disabled and neurodivergent folks; and more—is critical. Training programs that prioritize intersectional representation of the TGI community are better equipped to educate about the TGI community’s diverse needs, because people impacted by the health disparities that the Act seeks to address have insight into the possible solutions. It is essential that health plan and insurer staff understand that TGI health equity is not just a gender issue. TGI health disparities are compounded by barriers related to race, disability, age, body size, socioeconomic status, immigration status, and other social markers and identities. The breadth of interconnected needs and forms of oppression that TGI communities experience cannot be addressed if staff do not know how to recognize those needs and barriers. Therefore, it is crucial to ensure that representation of all lived experiences within the TGI community is centered to teach health plan and insurer staff how to provide quality trans-inclusive care.
Recommendations for TGI Quality Standards
In addition to building a training curriculum, the Working Group developed recommended standards for health plans and insurers to measure and improve patient experience and the quality of care provided to TGI enrollees. Once the state issues official guidance on the standards, health plans and insurers must comply to capture TGI enrollees’ health care experiences in order to identify and address barriers for TGI enrollees. The Working Group’s final report lists three main recommendations:
- Organize certain health equity and quality measures—such as breast cancer screening and depression screening—by sexual orientation, gender identity, and sex characteristics (SOGISC).
- Integrate the Working Group’s recommended questions and practices for collecting and reporting SOGISC data.
- Research and develop TGI quality measures in several focus areas, such as preventative health care, reproductive health care, organ-specific cancer screenings, and more.
One of the first steps to address health inequities among the TGI community is to understand where and how they occur. Collecting SOGISC data is an effective tool to identify health inequities and the final report provides best practices on how to do so. For example, questions should differentiate between gender identity and sex characteristics; enrollees should be allowed to check multiple boxes/categories and change their responses over time; and health plans and insurers should make it clear that the data is confidential, protected, and voluntary.
Despite several laws that have passed requiring SOGISC data collection, state agencies have been slow to comply. The Working Group’s recommendations build additional accountability and guidance for state agencies to improve in this area.
In 2023, 185 bills targeting gender-affirming care were introduced across the country—more than the previous five years combined—and another 148 bills have been introduced so far this year. California is the first in the nation to pass a law that protects gender-affirming care like the TGI Inclusive Care Act. Although California is a leader in protecting and expanding health care access and LGBTQ+ rights, the multifaceted barriers and discrimination identified by the Working Group’s final report show that there is still work to be done. The state has taken a major first step by convening the Working Group and releasing the final report. It is important that the state continues the momentum and improves on existing gaps to fulfill the mandates of the Act so TGI communities have the autonomy, dignity, and quality health care they deserve.
Rory Peters (they/them) is a law intern in our North Carolina office and a rising 3L at the University of Michigan Law School. Originally from Indiana, they went to IU for undergrad and worked at a public health policy and education organization before coming to law school. Last summer, Rory was awarded the MLaw Outlaws Public Service Fellowship to intern at the Legal Council for Health Justice in Chicago, where they worked with transgender clients and clients living with HIV/AIDS to apply for and maintain SSDI benefits. After graduation, Rory aspires to continue working with the transgender community, securing public benefits for clients, and advocating for more accessible and affordable health care for all.
