Nondiscrimination in Health and Health Education Programs or Activities (Section 1557 NPRM) Comment
August 13, 2019
The Honorable Alex M. Azar II
U.S. Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201
Re: Nondiscrimination in Health and Health Education Programs or Activities (Section 1557 NPRM), HHS-OCR-2019-0007, RIN 0945-AA11
Dear Secretary Azar and Mr. Severino,
On behalf of The Leadership Conference Education Fund, I write in response to the notice of proposed rulemaking (NPRM) on Section 1557 of the Patient Protection and Affordable Care Act (ACA) (“Health Care Rights Law” or “Section 1557”) that promotes discrimination in health care. The Leadership Conference Education Fund (Education Fund) is the research and education arm of The Leadership Conference on Civil and Human Rights, a coalition charged by its diverse membership of more than 200 national organizations to promote and protect the civil and human rights of all persons in the United States. The Health Care Rights Law is a major civil rights law and our members have advocated for its full and complete implementation since its enactment in 2010. The Education Fund strongly opposes any rollbacks of civil and human rights and is therefore deeply concerned by the harmful and discriminatory changes suggested by the U.S Department of Health and Human Services (HHS) in this proposed rulemaking.
Health care is a human right. Every person in our nation should be able to safely access health care without fear of discrimination, harassment, or persecution. Since it took effect on March 23, 2010, the Health Care Rights Law has prohibited discrimination on the basis of race, color, national origin (including language access), sex, age, or disability in health programs or activities that receive federal financial assistance or are administered by an executive agency or any entity established under Title I of the ACA. Section 1557 is the key nondiscrimination provision of the ACA, and builds upon existing civil rights laws to ensure that everyone in America has access to quality, affordable health insurance coverage and health care. The Health Care Rights Law is also the first federal law to ban sex discrimination in health care. Significantly, Section 1557 recognizes that individuals have complex identities and may be part of multiple protected classes and face discrimination because they belong to one or more of these classes.
During the previous administration, HHS undertook an extensive process to develop thoughtful regulations for the Health Care Rights Law. This included a Request for Information, a proposed rulemaking, as well as a final rule. In addition, the Office of Civil Rights (OCR) at HHS engaged in robust outreach and education efforts with individuals, community organizations, and providers regarding their rights and responsibilities under Section 1557. HHS considered more than 24,875 public comments submitted for the 2016 rule.
On May 29, 2019, OCR announced its proposal to eliminate key provisions of Section 1557 of the ACA. This new proposed rule promulgated by HHS ignores the reasoned process HHS previously undertook. If implemented, this civil rights rollback would harm millions of people in America by allowing health care providers to deny care to marginalized communities and worsen already existing health disparities in our country. The proposed rule would encourage discrimination against and eliminate/limit protections for individuals who are part of the LGBTQ community, people with limited English proficiency, women, and people with disabilities, exacerbating the barriers to coverage and discrimination in health care that these communities already face within our health care system today. Section 1557 addresses not only protections for each protected class covered, but the intersection of those protections. Therefore, an attack on the civil rights of one group in the NPRM is an attack on the civil rights of all.
The Leadership Conference Education Fund strongly recommends that HHS not finalize or implement the NPRM on Section 1557 regulations as well as the other conforming provisions. HHS should instead leave the 2016 final Section 1557 regulations in place in their entirety. Below is feedback on numerous portions of the proposed rulemaking.
I. The Proposed Rulemaking Would Impermissibly Limit the Scope of Applicability of Section 1557, Violating the Intent of the ACA
HHS seeks to significantly narrow the scope and applicability of Section 1557 in its proposed rulemaking, contradicting the plain meaning of the statute. In its 2016 Final Rule, HHS highlighted the purposes of the ACA and how Section 1557’s protections are inextricably linked to broader ACA coverage requirements and other protections: “a fundamental purpose of the ACA is to ensure that health services are available broadly on a nondiscriminatory basis to individuals throughout the country.” This interpretation is consistent with the Supreme Court’s recognition of the broader purpose of the ACA to “expand insurance coverage. . . . [and] ensure that anyone can buy insurance.”
The current regulations state that if an entity is principally engaged in providing or administering health services or health insurance coverage, all of its activities are covered by Section 1557 if any part receives federal financial assistance (FFA). Covered entities under the Health Care Rights Law include hospitals, clinics, and health care providers’ offices and issuers selling health insurance plans within and outside of the ACA Marketplaces. The proposed rule would limit the scope of entities covered under Section 1557. The NPRM suggests eliminating the current definition of FFA under the Health Care Rights Law and instead would narrowly construe what entities qualify as a recipient of FFA, defying the purpose behind the ACA.
HHS also proposes to exempt itself and other federal programs and agencies from the nondiscrimination requirements of Section 1557. Both the plain language of Section 1557 and the 2016 Final Rule established that any health “program or activity” administered by an Executive agency is subject to the law’s provisions. HHS now argues that Congress wanted to limit application of the Health Care Rights Law only to federal health programs or activities created under Title I of the ACA. If implemented, this regulatory scheme would not only lead to more discrimination, it would also lead to the absurd result of recipients of FFA being subject to Section 1557, but the programs themselves, and the agencies administering them, would be exempt.
Finally, the NPRM seeks to exempt a broad array of health insurance companies from the non-discrimination provisions of Section 1557, claiming in the proposed rule that “‘Health insurance’ is distinct from ‘health care.’” The proposed rule contends that health insurance is not a health program or activity within the meaning of the Health Care Rights Law. This is inconsistent with the plain meaning of the statute and would undercut application of the non-discrimination provision of the ACA through regulation.
II. The Proposed Rule Attempts to Limit Enforcement Mechanisms and Remedies under Section 1557
When Congress passed the ACA, it included remedies for discrimination under Section 1557. Every court that has ruled on the question has found that the statutory language of Section 1557 confers a private right of action for monetary damages. The statutory language of Section 1557 explicitly references and incorporates the “enforcement mechanisms” of the four civil rights laws listed, all of which include a private right of action. Congress specified that “[t]he enforcement mechanisms provided for and available under such title VI, title IX, section 504, or such Age Discrimination Act shall apply for purposes of violations of this subsection.” HHS proposes to remove the regulatory language that makes clear that a private right of action and monetary damages are available to redress violations of the Health Care Rights Law. It would also eliminate the regulation that makes money damages available to those who are harmed when Section 1557 is violated. The civil rights community strongly opposes this proposal.
HHS also proposes to delete in its entirety a rule of interpretation for Section 1557. The current provision makes clear that the four pre-existing civil rights laws referenced by Section 1557 (as noted above) set the floor for protections within Section 1557. This is consistent with Congressional intent that Section 1557 build and expand upon these existing civil rights laws while providing broad protection against discrimination in health care. Deleting the rule of interpretation will cause confusion and this proposal should not be finalized.
Finally, the current regulation states that covered entities with at least 15 employees must adopt a grievance procedure. The proposed rulemaking would eliminate the entirety of the existing Health Care Rights Law nondiscrimination notice and grievance procedure requirements, leading to more discrimination in health care and undermining the goals of the ACA.
III. If Implemented, the Proposed Rule Will Harm LGBTQ Individuals
The proposed rule attempts to eliminate anti-discrimination protections for the LGBTQ community, putting the lives of millions of people in this country at risk. The changes would remove sexual orientation, gender identity, and sex stereotyping as recognized forms of discrimination under the ACA. To be clear, the changes proposed in this rulemaking would not alter the statutory protections of Section 1557—federal courts could continue to apply Section 1557 more broadly. However, the proposed regulations would significantly narrow OCR’s enforcement of the Health Care Rights Law, encouraging discrimination against LGBTQ people in the health care system.
Although the law itself has not changed, the proposed rule would increase confusion for a community that already avoids medical treatment for fear of mistreatment. It would remove vital protections against the threats of discrimination that have become a defining aspect for too many members of the LGBTQ community when they engage with the health care system. The rule would discourage people from speaking out if they experience discrimination, eliminating the opportunity for any clear recourse against those who deny people essential care simply due to a patient’s gender identity or sexual orientation.
The proposed rule would allow health coverage plans to discriminate against LGBTQ individuals and deny coverage for gender-affirming care for transgender individuals. A 2018 report by Human Rights Watch shows that LGBT individuals are already twice as likely to be uninsured as non-LGBT individuals. According to the U.S. Transgender Survey, the uninsured rate for transgender individuals is higher than the rate for the overall population. Fourteen percent of transgender respondents were uninsured, compared to 11 percent of adults in the U.S. population. Transgender adults are also more likely to be uninsured and socioeconomically disadvantaged compared to cisgender adults.
The rule would have particularly harmful effects on the lives of transgender people. According to The Williams Institute, there are 4 million transgender adults and 150,000 transgender teens ages 13 to 17 in the United States who would no longer be protected against gender identity discrimination in health care if this rule is finalized. Transgender individuals face widespread discrimination when seeking coverage for gender-affirming care. Twenty-five percent of respondents experienced a problem with their insurance in the past year related to their being transgender, including being denied coverage for care related to gender transition. Twenty-five percent of those who sought coverage for hormones in the past year were denied, and 55 percent of those who sought coverage for transition-related surgery in the past year were denied coverage.
The proposed rule not only removes gender identity from the definition of sex discrimination, but it also erases sections of the existing regulations that prohibit insurance companies from excluding gender-affirming care as a covered service. According to the American Medical Association, “every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people and has called for health insurance coverage for treatment of gender dysphoria.”
The changes that result from this proposed rule could have devastating consequences for the mental health of transgender individuals. According to a 2016 study published in Transgender Health, many transgender people experience psychological distress related to the discrepancy between their birth sex and their gender identity. In some cases, these individuals experience psychological distress at such an extreme level that they experience a clinically significant condition called gender dysphoria. According to the American Psychiatric Association, gender dysphoria is associated with high levels of stigmatization, discrimination, and victimization, which contributes to transgender people’s negative self-image and increased rates of other mental disorders. A 2019 study on the psychological benefits of hormones and surgeries that align transgender people’s outward appearance with their gender identities showed that gender-affirming medical treatments are associated with improved psychological wellbeing, such as higher life satisfaction and lessened gender dysphoria.
According to a joint study by the American Foundation for Suicide Prevention and The Williams Institute, 41 percent of transgender respondents had attempted suicide at some point in their lifetime. Sixty percent of those who had attempted suicide had been refused treatment by a doctor or health care provider. Transgender individuals are at a higher risk of victimization and hate crimes than the general public, children with gender dysphoria are at a higher risk of emotional and behavioral problems, and adolescents and adults with gender dysphoria are at an increased risk for suicide.
More than half of all respondents to a 2010 Lambda Legal survey of LGBTQ people and people living with HIV said that they experienced some type of discrimination in health care, whether this involved health care professionals refusing to touch them or using excessive precautions, health care professionals using harsh or abusive language, being blamed for their health status, or health care professionals being physically rough or abusive. According to a 2017 study by the Center for American Progress, eight percent of lesbian, gay, and bisexual respondents reported that a health care provider refused to see them outright because of their sexual orientation or gender identity in the past year. The proposed rule does not recognize these forms of discrimination that many LGB individuals face as sex discrimination.
Without protections from discrimination, many transgender people avoid going to the doctor when they need medical care. According to the National Center for Transgender Equality’s 2015 U.S. Transgender Study, 23 percent of respondents did not see a doctor in the past year when they needed to because they believed they would be mistreated. Thirty-three percent of respondents reported having at least one negative experience with a health care provider in the past year based on their gender identity. Twenty-nine percent of transgender respondents reported that a healthcare provider refused to see them in the past year because of their sexual orientation or gender identity.
LGBTQ people of color in particular would face increased barriers to care if this rule were finalized. According to the Lambda Legal survey, LGBTQ respondents of color and low-income respondents in nearly every category surveyed experienced higher rates of discrimination and substandard care compared to white LGBTQ respondents. People of color living with HIV and LGB people of color were also at least twice as likely as white people to report experiencing physically rough or abusive treatment by medical professionals.
LGBTQ individuals already face pervasive discrimination and are refused coverage and care due to their gender identity, sexual orientation, and sex stereotyping. The rule would worsen the inequities that already exist, while giving health care providers and insurance plans a free pass to discriminate.
IV. The Proposed Rule Will Undermine the Rights of Individuals with Limited English Proficiency
Due to language barriers, individuals with limited English proficiency (LEP) can face challenges in accessing health care. LEP individuals often do not understand crucial information about their care and may be unfamiliar with the American health care system. And often, the health care providers serving LEP individuals do not understand the full details of their patients’ health care concerns. And the stakes are high—a 2010 study commissioned by the National Health Law Program found that patients lost their lives and suffered irreparable harm due to language barriers and the failure to provide appropriate language services. Protections for language access are also required in order to combat discrimination based upon national origin.
With this background in mind, the current regulations for Section 1557 include specific requirements to ensure that covered entities understand their obligations to ensure meaningful access for LEP individuals and also have clear instructions on how to comply with those obligations. Under the Health Care Rights Law, health care entities must notify individuals that they do not discriminate on the bases prohibited by Section 1557, inform them that appropriate language assistance services are available without charge and in a timely manner, and include information about how to file a complaint should these individuals face discrimination. A covered entity must also include taglines in the top 15 non-English languages in the entity’s state. The proposed rule would eliminate these notice and taglines requirements, creating barriers to care for LEP individuals and leaving them without the transparency they need about their health insurance and health care services.
Widespread lack of access to comprehensive and accurate information for LEP individuals leads to worse health outcomes. In 2017, 25.9 million people in the United States identified as LEP. According to an article published in the AMA Journal of Ethics, patients who are LEP experience high rates of medical errors with worse clinical outcomes than English-proficient patients, and they receive lower quality care. Compared to English-speaking patients, LEP patients have longer hospital stays when professional interpreters were not used at admissions and/or discharge. LEP individuals face a greater risk of infections, surgical delays due to difficulty understanding how to prepare for a procedure, and a greater chance of readmission for certain chronic conditions when they are unclear on how to manage their conditions and take medications. A 2009 study in the official journal of the American Academy of Pediatrics showed that Spanish-speaking patients whose families have a language barrier have a significantly increased risk for serious medical error during pediatric hospitalization compared with patients whose families do not have a language barrier.
The lack of adequate care that LEP patients receive is not only the result of insufficient language assistance services and resources. A 2009 article in the Journal of General Internal Medicine found that physicians underuse interpreters despite the evidence of benefits and immediate availability of these services. The proposed rule would misguidedly leave it to the discretion of individual providers to determine whether or not patients receive the language assistance services that allow these individuals to make informed decisions about their own health care.
The proposed rule fails to provide a sound rationale for overturning the 2016 final rule’s approach around language access. Instead, HHS now suggests that eliminating these provisions will reduce costs and that the alleged benefit of overturning these provisions would “far outweigh any costs of burdens.” This is a misguided approach, because it fails to adequately capture the immeasurable benefits of language access, including increased access and participation from underserved communities, improved health outcomes, and compliance with anti-discrimination laws. The cost-benefit analysis also fails to account for the costs to a consumer (as well as their family) when they are denied or delayed language assistance and their health suffers.
If implemented, the rule would encourage the very discrimination that Section 1557 was designed to prevent. The proposed rule would set a standard in this country that those who do not speak English fluently should not have access to quality health care.
V. The Proposed Rule Attempts to Reduce Access to Reproductive Health Care and Adopt a Blanket Religious Exemption
The administration’s proposed rule would dramatically reduce access to reproductive healthcare for millions of women, particularly low-income women and women of color who already face barriers to care. Section 1557 was the first federal statute to bar discrimination on the basis of sex in federally funded health care and health coverage, and its protections have been critical in ensuring equal access to health benefits by both men and women. The law has been used to address, for example, exclusions of maternity coverage from the benefits provided to certain female plan participants. Treating pregnancy differently, such as by excluding pregnancy care from an otherwise comprehensive insurance plan, is sex discrimination under civil rights laws such as Title IX and Title VII, and also sex discrimination under Section 1557.
HHS proposes to eliminate the definition of sex-based discrimination, which includes discrimination on the basis of pregnancy, false pregnancy, or termination of pregnancy. The proposed rule would permit health care providers, pharmacies, and insurance companies to cite personal or religious beliefs as a reason to deny care or coverage to a patient because of their sex or gender, limiting patients’ access to reproductive health care. As the Kaiser Family Foundation noted in its analysis of the NPRM, “HHS proposes allowing health care providers and other covered entities to invoke blanket abortion and religious objection exemptions from the regulations’ general prohibition on sex discrimination.” The rule would explicitly allow providers to refuse to perform an abortion and allow insurance companies to refuse to provide coverage for abortions. HHS suggests inappropriately incorporating abortion and religious exemptions included in Title IX, provider conscience provisions including the Religious Freedom Restoration Act, the Weldon Amendment, the Coats-Snow Amendment, and the Church Amendments, as well as several appropriations riders (including the Hyde and Helms Amendments) into Section 1557 through the NPRM. These statutes and legislative riders were not referenced in the ACA and it is impermissible to add them via regulation.
The rule’s proposed religious exemption would also allow health care providers and insurance companies to refuse care and coverage to LGBTQ individuals on religious grounds. This discrimination is not limited to gender-affirming care for transgender individuals – allowing health care entities to use religion as a reason to discriminate will result in LGBTQ individuals being denied necessary and life-saving treatment.
VI. The Rulemaking Seeks Comment on Proposals that Would Harm Access to Health Care for People with Disabilities
The NPRM seeks comment on a number of proposals that if adopted would also negatively impact people with disabilities, weakening standards for accessibility in health care facilities and eliminating provisions regarding benefit design discrimination.
The current rule requires covered entities to provide appropriate auxiliary aids and services to people with impaired sensory, manual, or speaking skills. The proposed rule seeks comment on whether to propose an exemption from the auxiliary aids and services requirement for covered entities with fewer than 15 employees. An exemption for an entity with fewer than 15 employees would roll back the civil rights of people with disabilities. If these requirements were removed, certain health care entities would no longer be required to provide people who are deaf, hard of hearing, blind, or visually impaired with services that are necessary for them to receive the care that they need. Data shows that people with disabilities often obtain their health care from specialists or local providers with few employees—this is particularly true in rural areas. The American Medical Association’s Physician Practice Benchmark Survey in the period from 2012-16 found that a majority of physicians continue to work in small practices, with 57.8 percent in practices of 10 or fewer physicians, and 37.9 percent working in practices with fewer than 5 physicians in 2016. Creating this exemption would therefore have a wide effect, harming the ability of people with disabilities to access care.
The current rule requires covered entities to make reasonable modifications in policies, practices, and procedures to avoid disability-based discrimination, unless doing so would fundamentally alter the nature of the health program or activity. The proposed rule seeks comment on whether this language should be revised, and whether health care entities can be exempted from abiding by this provision if it would impose undue hardship.
OCR also seeks comments on whether HHS should change certain accessibility standards. The rule asks about removing requirements for building construction and architectural standards. While the current rule adopts the 2010 ADA Standards for Accessible Design for entities that receive federal funding, the proposed rule seeks comment on whether these standards should be applied at all. The removal of these standards could permit health care entities to fail to have elevators, accessible entrances, accessible restrooms, or text telephones (TTYs) —which allow people who are deaf, hard of hearing, or have speech impairment to use the telephone by typing and reading text—among other crucial standards that allow people with disabilities equal access to care.
VII. The Proposed Rule Would Eliminate the Prohibition on Discriminating Based on Association
Under the 2016 Final Rule, discrimination on the basis of association with a protected class is expressly prohibited. The proposed rulemaking seeks to eliminate this provision, offering no explanation for doing so.
The current regulations note that the statute does not limit “the prohibition to discrimination based on the individual’s own race, color, national origin, age, disability or sex.” Further, we noted that a prohibition on associational discrimination is consistent with longstanding interpretations of existing antidiscrimination laws, whether the basis of discrimination is a characteristic of the harmed individual or an individual who is associated with the harmed individual.”
The language contained in the current regulation mirrors the language of Title I and Title III of the Americans with Disabilities Act (ADA), which protect against discrimination based on association or relationship with a person with a disability. Congress intended that the Health Care Rights law provide at least the same protections for patients and provider entities. The current regulation recognizes that this protection extends to providers and caregivers, who are at risk of associational discrimination due to their professional relationships with patients, including those patient classes protected under Section 1557.
Congress intended the Health Care Rights Law to protect against discrimination by association, and these provisions should be retained.
If implemented in whole, the proposed rulemaking would sow discrimination back into the health care system. The proposals suggested by HHS would result in a system where a health care provider could refuse care to someone because of their sexual orientation or transgender identity, someone who does not speak English could be denied information that is critical to their health and well-being, and a woman could face discrimination in receiving care after a miscarriage or ectopic pregnancy. It is also important to acknowledge that individuals may face discrimination due to multiple factors, and individual experiences often do not fit neatly into the categories outlined above.
The Leadership Conference Education Fund strongly encourages the administration not to finalize this rule. Rather than promoting discrimination in health care, HHS should be working to ensure robust implementation and enforcement of Section 1557 of the ACA throughout the health care system.
Thank you for the opportunity to submit The Education Fund’s comments on this proposal. If you have any questions, please contact Emily Chatterjee at [email protected]
President and CEO
The Leadership Conference Education Fund
 Patient Protection and Affordable Care Act, Pub. L. No. 111‐148, 124 Stat. 119 (Mar. 23, 2010); 42 U.S.C. § 18116.
 Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq.), Title VII of the Civil Rights Act of 1964 (42 U.S.C. § 2000e et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681 et seq.), Section 794 of Title 29, or the Age Discrimination Act of 1975 [42 U.S.C. § 6101 et seq.].
 U.S. Department of Health & Human Services, Request for Information Regarding Nondiscrimination in Certain Health Programs or Activities, 78 Fed. Reg. 46558 (Aug. 1, 2013); U.S. Department of Health & Human Services, Nondiscrimination in Health Programs and Activities (Notice of Proposed Rulemaking), 80 Fed. Reg. 54172 (Sept. 8, 2015); U.S. Department of Health & Human Services, Nondiscrimination on the Basis of Race, Color, National Origin, Sex, Age, or Disability in Health Programs or Activities Receiving Federal Financial Assistance and Health Programs or Activities Administered by the Department of Health and Human Services or Entities Established under Title I of the Patient Protection and Affordable Care Act, 45 C.F.R. Part 92, 81 Fed. Reg. 31376 (May 18, 2016) (hereinafter “2016 Final Rule”).
 2016 Final Rule.
 2016 Final Rule.
 King v. Burwell, 135 S. Ct. 2480, 2493 (2015).
 45 C.F.R. § 92.4.
 42 U.S.C. § 18116(a); 45 C.F.R. §§ 92.2(a), 92.4.
 42 U.S.C. § 18116 (a); 42 C.F.R. §§ 92.1, 92.2, 92.4.
 84 Fed. Reg. 27846 (Pg. 27862).
 42 U.S.C. § 18116(a).
 Thoreson, Ryan. “‘You Don’t Want Second Best’: Anti-LGBT Discrimination in US Health Care.” Human Rights Watch. July 2018. Pg. 5. https://www.hrw.org/sites/default/files/report_pdf/us_lgbt0718_web.pdf.
 James, Sandy E.; Herman, Jody L.; Rankin, Susan; Keisling, Mara; Mottet, Lisa; and Anafi, Ma’ayan. “The Report of the 2015 U.S. Transgender Survey.” National Center for Transgender Equality. December 2016. Pg. 94. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf.
 Gonzales, Gilbert and Henning-Smith, Carrie. “Barriers to Care Among Transgender and Gender Nonconforming Adults.” The Milibank Quarterly: A Multidisciplinary Journal of Population Health and Health Policy. December 11, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5723709/.
 “HHS aims to roll back non-discrimination protections for more than 1.5 million transgender people.” The Williams Institute. April 28, 2019. https://williamsinstitute.law.ucla.edu/press/hhs-rules-conscience-and-1557/.
 “Health insurance coverage for gender-affirming care of transgender patients.” American Medical Association. 2019. Pg. 1. https://www.ama-assn.org/system/files/2019-03/transgender-coverage-issue-brief.pdf.
 Hughto, Jaclyn M. White and Reisner, Sari L. “A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals.” Transgender Health. Jan. 1, 2016. https://www.liebertpub.com/doi/pdf/10.1089/trgh.2015.0008.
 “What Is Gender Dysphoria?” American Psychiatric Association. https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.
 Cai, Xiang, Hughton, Jaclyn M. W., Reisner, Sari L., Pachankis, John E, and Levy, Becca R. “Benefit of Gender-Affirming Medical Treatment for Transgender Elders: Later-Life Alignment of Mind and Body.” LGBT Health. January 16, 2019. https://doi.org/10.1089/lgbt.2017.0262.
 Haas, Ann P., Rodgers, Philip L., and Herman, Jody L. “Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey.” American Foundation for Suicide Prevention, the Williams Institute. January 2014. https://williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-Final.pdf.
 Tillery, Beverly. “When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV.” Lambda Legal. 2010. https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf.
 Mirza, Shabab Ahmed and Rooney, Caitlin. “Discrimination Prevents LGBTQ People from Accessing Health Care.” Center for American Progress. 2017. https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/.
 James, Sandy E.; Herman, Jody L.; Rankin, Susan; Keisling, Mara; Mottet, Lisa; and Anafi, Ma’ayan. “The Report of the 2015 U.S. Transgender Survey.” National Center for Transgender Equality. December 2016. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf.
 Mirza, Shabab Ahmed and Rooney, Caitlin. “Discrimination Prevents LGBTQ People from Accessing Health Care.” Center for American Progress. 2017. https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/.
 Tillery, Beverly. “When Health Care Isn’t Caring: Lambda Legal’s Survey on Discrimination Against LGBT People and People Living with HIV.” 2010. Pg. 11. https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf.
 Quan, Kelvin and Lynch, Jessica. “The High Costs of Language Barriers in Medical Malpractice.” University of California, Berkley School of Public Health and National Health Law Program. https://healthlaw.org/resource/the-high-costs-of-language-barriers-in-medical-malpractice/.
 Rodriguez, Carmen Heredia. “Non-English Speakers Face Health Setback If Trump Loosens Language Rules.” Kaiser Health News. June 24, 2019. https://khn.org/news/foreign-language-health-notices-non-english-speakers-trump-administration-rules/.
 Green, Alexander R. and Nze, Chihioke. “Language-Based Inequity in Health Care: Who Is the ‘Poor Historian’?” AMA Journal of Ethics. March 2017. Pg. 263. https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-05/medu1-1703.pdf.
 “Overcoming the challenges of providing care to LEP patients.” The Joint Commission. May 2015. Pg. 1. https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_13_May_2015_EMBARGOED_5_27_15.pdf.
 A.L. Cohen. “Are language barriers associated with serious medical events in hospitalized pediatric patients?” Pediatrics. September 2005. https://www.ncbi.nlm.nih.gov/pubmed/16140695.
 Diamond, Lisa C.; Schenker, Yael; Curry, Leslie; Bradley, Elizabeth H.; and Fernandez, Alicia. “Getting By: Underuse of Interpreters by Resident Physicians.” Journal of General Internal Medicine. Dec. 17, 2008. https://link.springer.com/article/10.1007%2Fs11606-008-0875-7.
 See, e.g., “NWLC Section 1557 Complaint: Sex Discrimination Complaints Against Five Institutions.” National Women’s Law Center. http://www.nwlc.org/resource/nwlc-section-1557-complaint-sex-discrimination-complaints-against-five-institutions. (Section 1557 complaints filed against five institutions that exclude pregnancy coverage for plan beneficiaries who are dependent children of employees at institutions).
 Musumeci, MaryBeth; Kates, Jennifer; Dawson, Lindsey; Salganicoff, Alina; Sobel, Laurie; and Artiga, Samantha. “HHS’s Proposed Changes to Non-Discrimination Regulations Under ACA Section 1557.” Henry J. Kaiser Family Foundation. July 1, 2019. Pg. 4. https://www.kff.org/disparities-policy/issue-brief/hhss-proposed-changes-to-non-discrimination-regulations-under-aca-section-1557/.
 Keith, Katie. “HHS Proposes To Strip Gender Identity, Language Access Protections From ACA Anti-Discrimination Rule.” May 25, 2019. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20190525.831858/full/.
 Cane, Carol K. ” Policy Research Perspectives: Updated Data on Physician Practice Arrangements: Physician Ownership Drops Below 50 Percent.” American Medical Association. 2017. Pgs. 4-5. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf. The Benchmark surveys are of practicing physicians who provide a minimum of 20 hours of patient care/week in one of the 50 states or the District of Columbia, and who are not employed by the federal government.
 “Guidance on the 2010 ADA Standards for Accessible Design.” Department of Justice. Sep. 15, 2010. https://www.ada.gov/regs2010/2010ADAStandards/Guidance_2010ADAStandards.pdf.
 45 C.F.R. § 92.209.
 81 Fed. Reg. 31439.
 42 U.S.C. §§ 12112, 12182 (2012).
 28 C.F.R. pt. 35, app. B (2015) (interpreting Title I and Title III of the ADA to protect “health care providers, employees of social service agencies, and others who provide professional services to persons with disabilities”).