Analysis Health Systems

How Health-Care Reform Could Improve Employment Prospects for People With Disabilities

Sheila Bapat

In attempting to reverse troubling unemployment trends among persons with disabilities, disability rights advocacy groups are looking to the health-care sector as a solution.

As job growth remains persistently sluggish, women and men with disabilities are among those who face the toughest employment challenges. And in attempting to reverse these trends, some disability rights groups are looking to the promise of job creation under the Affordable Care Act (ACA) as a solution.

The current unemployment rate for women with disabilities in the United States is 15.8 percent—more than double that of women without disabilities. Similar trends hold true for men with disabilities. Related to this, poverty rates for persons with disabilities are also disproportionately high.

“The saying ‘last hired, first fired’ is unfortunately very true for many people with disabilities,” Sarah Triano, executive officer of the California Committee on Employment of People with Disabilities (CCEPD), told Rewire. “Right now, as people are slowly beginning to get jobs again, people with disabilities still are not.”

October is National Disability Employment Awareness Month, and in response to the troubling national employment statistics, state and federal policymakers have for some time been working on ways to improve employment prospects for persons with disabilities. The National Governors Association (NGA) released a report just last month guiding governors on the severity of the problem and how they may take actions within their state to reverse these employment trends. South Carolina and Connecticut, for example, have recently worked with Walgreens and other retail companies to develop a plan to hire more people with disabilities.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

But retail jobs often do not pay very well or offer health insurance—realities of the current economy that could leave many persons with disabilities in tough economic situations. Thus some groups are encouraging employment of people with disabilities in better-paying health-care positions. And among its many effects, health-care reform is expected to increase the number of available jobs in health care.

As part of the ACA, the Obama administration launched the Health Care Innovation Challenge, a program that awards grants to those with compelling ideas about how to deliver health care. The program could increase the number of “mid-level” health-care workers, such as nurse practitioners, community health-care workers, and nurse-midwives.

But beyond improving employment statistics, there are far deeper reasons for persons with disabilities to pursue jobs in the health-care sector. A longstanding injustice many people with disabilities face is the way in which the medical world views them.

“The medical model of disability sees people with disabilities as objects to be cured or fixed, that they’re not natural,” Triano said. “Whereas a more social or political model takes a view that disability is a natural part of human diversity, and that instead what needs to be fixed is not the person, but the societal discrimination she faces.”

The National Organization of Nurses with Disabilities (NOND), a group founded and governed by nurses with disabilities, is among the advocates who are working to build a pipeline of persons with disabilities to fill health-care positions. In August, NOND signed on to an agreement with the U.S. Department of Labor’s Office of Disability Employment Policy expressing support for the hiring of persons with disabilities in the health-care industry—an agreement that can give NOND clout as they organize.

Through increasing the number of people with disabilities in health-care positions, CCEPD, NOND, and other groups aim to transform the medical model, thereby improving employment while also applying the social and political approach to meeting the needs of persons with disabilities.

“Disability advocates have worked hard for equality in transportation, education, employment, recreation, and other realms, but health care is one of the last domains for advocacy,” said NOND president Beth Marks. “And there is great power to transform the medical model within health-care settings. If you have daughter who uses wheelchair, and that child’s health professional wheels into the room, you’ve just in that one moment transformed that kid’s life.”

However, improving employment of people with disabilities in health care or any sector also requires major policy shifts as well as breaking barriers in many places of employment.

Currently, to qualify for disability in the United States, the Social Security Act (SSA) requires a person be completely unable to work. As a result, some people with disabilities who are eligible for benefits feel compelled to rely on the support to survive rather than pursuing work in a job market that is not friendly to them—even if they prefer to work.

As scholar H. Stephen Kaye of the University of California at San Francisco found,

Despite a widespread belief that government disability benefits provide an adequate safety net for working age adults with disabilities—perhaps even an enticement to leave the labor force when times are tough—the very high rate of unemployment following job loss indicates that a large proportion of those losing jobs either need to remain in the labor force or choose to do so.

Though it provides essential benefits for many, the SSA’s definition of disability—like the medical field—is perhaps also a model that can marginalize some people with disabilities who need or prefer to be employed.

To fight this policy model and to build the pipeline of persons with disabilities for health-care positions, workplace discrimination should also be addressed more fully. Nursing is currently an occupation with a high forecasted growth rate nationally and in California, and is also dominated by women. Yet nursing schools and employers are still reluctant to accommodate nurses with disabilities.

“Despite the potential for students with disabilities to enrich the nursing profession, nurse educators may be perpetuating historical attitudes, values, and practices that exclude students with disabilities from gaining admission,” Marks wrote in a journal article earlier this year.

Professionals with disabilities who now lead advocacy groups like NOND and CCEPD represent stories of triumph in the face of tremendous challenges presented by schools and employers’ refusal to accommodate them over the course of their careers. Triano, 39 and now a leader in the disability rights community, spent much of her life experiencing such barriers to education and employment. Triano has a hereditary immune system disorder, and she also identifies as a person with mental health disabilities. “I graduated from UC Santa Barbara, Phi Beta Kappa and valedictorian, and I wanted to go to law school,” she said.

But when she was applying to law school, the Law School Admissions Council would not accommodate her need for more frequent bathroom breaks while taking the Law School Admissions Test. “So I decided I didn’t want to go to law school, as I knew I was going to get stuck fighting for accommodations in law school, for the bar exam, and so on.”

Triano then began a PhD program in disability studies, but she was denied health insurance for her preexisting conditions. She was forced to drop out of school, and accept a position at an independent living center so that she could have health insurance coverage and a paycheck.

She worked her way up in the disability advocacy community and now leads the CCEPD, after she was appointed in May by Gov. Jerry Brown.

“It’s been a long journey,” she said.


Dignity Health Sued Over Refusal to Offer Insurance Coverage for Transition-Related Care

Imani Gandy

“I was shocked when Dignity, which is supposed to be in the business of healing and holds itself out to the public as a bastion of ‘human kindness,’ told me they would not authorize insurance coverage for my doctor-prescribed treatment,” Joe Robinson said in a statement released by his attorneys at the American Civil Liberties Union (ACLU).

Joe Robinson, a transgender man and operating room nurse at a Dignity Health medical center in Arizona, has alleged in a lawsuit filed Monday that his employer’s insurance policy of depriving coverage for gender dysphoria is discrimination on the basis of sex, in violation of Title VII of the 1964 Civil Rights Act.

Because Dignity Health, which operates the fifth-largest health-care system in the country, excludes insurance coverage for gender dysphoria—or “sex transformation surgery,” as the insurance policy states—Robinson has borne the cost of his transition treatment. This included hormonal therapy and a double mastectomy. According to Robinson’s complaint, he requested coverage for phalloplasty, but his claim was denied; he says he cannot afford to pay for that surgery out of pocket.

“I was shocked when Dignity, which is supposed to be in the business of healing and holds itself out to the public as a bastion of ‘human kindness,’ told me they would not authorize insurance coverage for my doctor-prescribed treatment,” Robinson said in a statement released by his attorneys at the American Civil Liberties Union (ACLU).

“All I want is the same health benefits other, non-transgender Dignity employees receive, which is coverage for medically necessary treatments,” he continued.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

On May 16, the Equal Employment Opportunity Commission (EEOC), the federal agency tasked with enforcing workplace anti-discrimination laws, determined that Robinson could proceed with a lawsuit against Dignity Health. That lawsuit, which was filed in federal court in California, alleges that Dignity Health’s policy singles out transgender employees employees for unequal treatment.

In response to Robinson’s original EEOC complaint, Dignity Health claimed that its policy was not discriminatory because “health benefits under the Dignity plan are not provided for any personality disorders, including sexual/gender identity disorders and behavior and impulse control disorders.”

Robinson counters that the medical community does not consider gender dysphoria to be a “personality disorder.” His complaint notes that insurance companies have previously excluded coverage for transition-related care based on the erroneous assumption that such treatments were cosmetic and experimental—assumptions, he says, that have no basis in medical science today.

The World Professional Association for Transgender Health has published standards of care for gender dysphoria that have been recognized as authoritative by leading medical organizations, the U.S. Department of Health and Human Services, and federal courts, according to the complaint. Under those standards, it reads, medically necessary treatment for gender dysphoria “may include hormone therapy, surgery (sometimes called ‘sex reassignment surgery’) and other medical services that align individuals’ bodies with their gender identities.”

In September of last year, Robinson’s fiancée, who also works at Dignity Health, emailed Dignity Health’s CEO, Lloyd Dean, to ask him to remove the “sex transformation” exclusion from the company’s health plan so that Robinson could receive coverage for his medically necessary care, according to the complaint.

Nearly two months later, the complaint continues, Dignity Health’s chief human resources officer informed Robinson’s fiancée that Dignity Health had found no evidence of discriminatory practice in the administration of its health plan.

Robinson’s lawsuit comes at a crucial time in the legal battle for transgender rights. The primary focus of that battle has been on bathrooms, with states and school boards across the country rushing to propose discriminatory legislation that prohibits transgender people from using the bathroom that aligns with their gender identity.

Eleven states and state officials in late May filed a joint lawsuit challenging the Obama administration’s “Dear Colleague” letter sent to public schools nationwide, arguing that the letter, which says Title VII and related statutes protect transgender people from discrimination under the federal definition of “sex,” is beyond the scope of the administration’s authority.

North Carolina, meanwhile, is embroiled in a pair of lawsuits with the Department of Justice over HB 2, the recently enacted legislation that forces transgender North Carolinians to use the bathroom that does not align with their gender identity in public buildings and schools. Gov. Pat McCrory (R) sued the Obama administration for its “radical reinterpretation of Title VII of the Civil Rights Act of 1964 which would prevent plaintiffs from protecting the bodily privacy rights of state employees while accommodating the needs of transgendered [sic] state employees.”

Also in North Carolina, Joaquín Carcano has sued the state, alleging that HB 2 discriminates against him and all transgender people on the basis of sex in violation of Title VII and Title IX of the U.S. Education Amendments of 1972.

Robinson’s attorneys see his lawsuit as complementing the ongoing lawsuits regarding bathroom discrimination.

“Transgender people continue to face discrimination in a wide array of contexts, including employment, housing, education, healthcare and more,” ACLU staff attorney Joshua Block wrote to Rewire in an email. “In each of these contexts, as courts are recognizing that discrimination against transgender people is discrimination on the basis of ‘sex,’ transgender people are finally able to fight this discrimination as a violation of our civil rights laws.”

News Health Systems

Here’s How Hospitals Can Improve Health Care for Trans People

Kanya D’Almeida

Discrimination against trans patients ran the gamut from violence and harassment at the hands of medical professionals or hospital staff to verbal abuse in medical settings, according to the analysis.

A trio of civil rights groups on Wednesday released a set of guidelines to help hospitals improve health-care access and outcomes for transgender people.

The guidance comes after the federal government strengthened nondiscrimination protections for transgender patients under Section 1557 of the Affordable Care Act (ACA).

The final rule to Section 1557—which builds on a history of federal civil rights laws—prohibits the “denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity, and sex stereotyping,” according to the Department of Health and Human Services (HHS). The rule mandates that covered health programs and activities under the ACA “treat individuals consistent with their gender identity.”

Wednesday’s publication serves as a revised update to a 2013 report coauthored by Lambda Legal, the Human Rights Campaign (HRC), and the Committee on Lesbian, Gay, Bisexual and Transgender Rights of the New York City Bar Association on best practices in transgender care. The report’s authors recommended, among other measures, that hospitals adopt nondiscrimination policies with regard to gender identity and expression, and amend their respective Patients’ Bill of Rights to provide for transgender patients, including the right to privacy, and freedom from abuse and harassment based on gender identity.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

New recommendations in the updated document offer tips for appropriate collection of gender identity data—such as accurate pronouns—in electronic health records, and policy recommendations that would strengthen access to hormone therapy, which refers to the use of estrogens or androgens to induce physical or psychological characteristics consistent with a person’s gender identity.

Advocates contend that transgender people face serious barriers to quality and affordable health care: an analysis of the 2011 National Transgender Discrimination Survey of nearly 6,400 trans and gender non-conforming participants found that 19 percent of respondents reported being refused care as a result of their gender identity, while 28 percent postponed or delayed needed care due to discrimination.

Discrimination against trans patients ran the gamut from violence and harassment at the hands of medical professionals or hospital staff to verbal abuse in medical settings, according to the analysis. Respondents to the 2011 survey, which represents the most up-to-date and comprehensive data on discrimination against the trans community, reported being subjected to unnecessary and invasive physical exams, mockery, and violations of their privacy.

About 2 percent of respondents said they were physically attacked in a doctor’s office, while 28 percent said they experienced verbal harassment in a medical setting.

Survey participants reported incidents in which doctors conducted unnecessary pelvic exams, and one patient—whose gender identity was different from their sex as assigned at birth—said a doctor forcibly examined their genitals and discussed the case with other hospital workers in violation of HHS’ Health Information Privacy Act (HIPAA).

Authors of the revised guidelines say that many trans people opt to disengage themselves from the health-care system altogether, rather than endure abusive and insensitive treatment, resulting in poor health outcomes for the trans community.

“Just 21 percent of hospitals participating in the HRC Foundation’s 2016 Healthcare Equality Index (HEI) had specific policies outlining procedures and practices to eliminate bias and insensitivity toward transgender patients,” Tari Hanneman, deputy director of the organization’s Health and Aging Program, said in a press release issued Wednesday.

“This revised publication will go a long way in helping more hospitals adopt crucial policies and practices to ensure that transgender patients are welcomed and treated with appropriate care,” said Hanneman, who authored the HEI, which evaluated more than 2,000 health facilities for the 2016 index.

The revised document offers policy recommendations pertaining to patients’ access to personal items that would help with gender expression—such as makeup and gender appropriate clothing—and other items that assist with gender presentation, including material used in binding, padding, and tucking.