Kellan Baker is a PhD candidate in health services research at Johns Hopkins University. He is a part of the Health Policy Research Scholars Cohort 2017.
Before we begin, tell us a little bit about yourself and what your research interests are?
I’m a rising fourth-year doctoral candidate in health services research at the Johns Hopkins School of Public Health. My field looks at how to design, deliver, and pay for health care services, and my particular area of focus within that field is transgender health. My dissertation explores the costs and benefits of insurance coverage for gender-affirming care, which is important both for transgender people specifically and for the larger question of how to change our health system to make sure that all of us can get the care we need, when we need it.
What’s the story behind why you’re doing what you’re doing?
In my life, I have been every letter in the LGBTQ acronym: I came out as a lesbian when I was in high school, transitioned from female to male in my mid-twenties, and I now identify as bisexual or queer, though most people looking at me probably assume I’m gay. I transitioned while living in Russia, where I was working as a translator after I graduated from college.
Transitioning in Russia was complicated—I got hormone therapy by volunteering as a research subject for the Russian National Institute of Endocrinology—but eased by my American citizenship, which allowed me to petition a U.S. court to recognize my name and gender change. Russia, by contrast, had no clear legal or medical policies in place for gender transition. Navigating the different systems in these two countries was a crash course in how policy impacts people’s well-being by opening opportunities for some while limiting the lives of others.
After several years abroad in Russia and Austria, I returned to the U.S. in the summer of 2008 to pursue joint master’s degrees in public health policy and international development in Washington, D.C. I chose public health because it helps explain how social, economic, and political conditions shape our lives. These conditions—which in public health we call the social determinants of health—are manifestations of the systems that distribute resources, protection, and power across society, and they mediate exposure to health hazards such as poverty, discrimination, and violence.
My original goal was to go back abroad to work in global public health, but in the 2008 election, my home state of California brought me up short by passing Proposition 8, which eliminated marriage for same-sex couples. Ten years earlier, I had surreptitiously stolen anti-gay yard signs during a previous campaign against marriage equality in California, and in 2008 I joined a nationwide movement that was organizing protests in all 50 states and D.C. The LGBT leaders who marched with me on the National Mall invited me to Creating Change, the largest LGBT advocacy conference in the country, and I was hooked.
I was part of the first class of interns in the Obama Administration and spent the next eight years working in nonprofits and think tanks in D.C. I decided to go back for a PhD in 2016 because I realized that if I wanted to be more effective in shaping policy, I needed to gain the credentials that would give me confidence in rooms full of experts and skills to bring hard data to the table about the damage that discrimination and disparities do to our communities.
Tell us about a project you are currently working on that you are excited about?
I began working on my dissertation recently enough that I’m still excited about it! My dissertation has three aims: using machine learning techniques to identify transgender people in an insurance claims database, assessing whether nondiscrimination laws help transgender people get gender-affirming medical care, and using budget impact analysis to quantify how much that care costs.
These aims all reflect work that I was involved in before I went back to school. The most fundamental piece for me is data—data are really just stories about who we are and what we need, and it’s impossible to create effective policy without those stories. It’s very common for U.S. federal surveys to not collect sufficient data about communities experiencing health disparities, which then becomes an excuse for policymakers to not take any action about those disparities: no data, no problem. Part of my goal with the first aim is to look for new ways to gather data about transgender folks that describe the difficulties we face and inform better policies to address them.
My second aim assesses the impact of a 2016 federal regulation that I worked on, which bans discrimination against transgender people in health insurance and health care. The Trump administration has recently proposed new policies that eviscerate these protections while giving cover to medical providers who claim a religious objection to treating transgender people. One of the administration’s claims is that the 2016 regulation doesn’t work—that nondiscrimination protections don’t help people get the care they need. My second aim looks at whether that claim is true. My hypothesis—spoiler alert!—is that it isn’t, but I want to know what the data actually say.
Finally, I’m very interested in both the moral and the money arguments for why we need to end health disparities. The moral argument is that we need to eliminate health disparities because it’s immoral for the richest country in the world not to invest in building a culture of health and achieving health equity for all. The money argument, which was a new perspective for me when I started my PhD program, invokes the language of economic efficiency to point out that health disparities are literally a drag on the economy: the founding director of HPRS, Thomas LaVeist, and Darrell Gaskin from Johns Hopkins estimated in 2011 that over just three years, health disparities based on race and ethnicity alone caused $230 billion in direct medical costs and more than $1 trillion in indirect costs associated with preventable morbidity and mortality. They conclude that we should address health disparities not just because it’s the right thing to do, but because health equity’s benefits greatly exceed its costs.
For people unfamiliar with your research area, what is one piece of information you think is important for them to know?
It’s important to know that while transgender people come from every kind of background and have all kinds of different experiences, an experience that we all share is one or more encounters with hatred, fear, violence, or discrimination. Transgender people aren’t a menace or a media myth—we are real people just like anyone else, and we should be able to be authentically ourselves and be safe visiting the doctor, going to school, or just walking down the street.
Who is a researcher you admire and why?
An inspiration to me is my friend Sari Reisner, a trans-identified researcher who has been a major driving force in the development of transgender health as a field and who also has the uncanny ability to turn his research focus on exactly the questions that most need answering from a policy perspective. Every letter to policymakers, regulatory comment, and policy memo in this field has multiple citations from Sari’s work, and the high-quality evidence that he shares in his prolific writing has helped secure policy wins such nondiscrimination protections, government recognition of LGBT health disparities, advances in sexual orientation and gender identity data collection, and new federal investments in LGBT health and health disparities research. Though my focus will always be more on policy applications than pure research, the bar for research rigor and impact that I strive for (but I’m sure will never hit!) is set by Sari’s work.
How has being an HPRS Scholar helped you during your time as a doctoral candidate?
HPRS has revolutionized my understanding of how other fields contribute to the fight for health equity. I came to public health via a fairly nontraditional path, but my time working in health policy had narrowed my horizons to the minutiae of things like insurance benefit design, and I stopped listening to a lot of voices outside the echo chamber of health wonks talking to other health wonks about the news of the day. HPRS has introduced me to scholars from all different fields who talk so eloquently about how their work intersects with health and who have reignited my curiosity about where good ideas and effective champions for health equity come from.
Earlier this year, HPRS made it possible for me to participate in a program called 10.10.10, which brings together 10 entrepreneurs for 10 days and invites them to tackle 10 “wicked problems”: in the health sector, these are things like fragmented care, inaccessible personal health information, and racial disparities at the point of care. The premise of 10.10.10 is that entrepreneurs and businesses have equal responsibility—and potentially new solutions—to bring to bear on these problems. HPRS had already been encouraging me to think in these directions, but then the program went the extra mile to actually send me to be part of one of the start-up teams working with entrepreneurs to help them understand the wicked problems and begin to formulate a response. The 10 days were a fascinating introduction to business concepts like start-ups, investors, and series A and B funding rounds, and the experience gave me a lot more confidence in feeling that I will be able to effectively bring in people and resources from outside my traditional nonprofit world to contribute toward the goal of health equity.
In the RWJF HPRS program we have worked with you to help you think further about using your research to develop policy. If you could use your research to change any policy, what policy would it be?
My top priority would be universal health coverage. It is obscene, criminal, immoral—no single word is strong enough—that access to lifesaving health care in this country is rationed by income. Marginalized communities like transgender folks are the proverbial canaries in the coal mine: we’re singing our hearts out in a warning of what happens when anyone, transgender or not, runs up against a health system whose primary incentive is to make profits rather than save lives. Health care is a human right, and the government should have the ultimate responsibility for ensuring that care is accessible, affordable, and comprehensive not just for a handful of people, but for all of us.
I would also like to wave a magic wand to upend the U.S. health system so that medicine is considered a branch of public health rather than vice versa. There was a fascinating session at the 2019 HPRS Annual Leadership Institute where scholars who had visited Cuba described how the Cuban medical system, including doctors and hospitals, is embedded within the broader public health system that is responsible for the health not just of any one individual but of the population as a whole. We learn in our HPRS classes that only about 10% of a person’s health is due to medical care: the largest contribution to health by far is from the environment, including transportation systems, food policy, distribution of income and wealth, and other social determinants. If we want to focus our attention on the issues that matter most for building a culture of health, we do need universal coverage to make sure that people can get medical care, but we also need to highlight and address the challenges they encounter outside the doctor’s office.
Ok, here’s a fun question to wrap things up. If you could visit any place in the world, where would you choose to go and why?
The only continent I haven’t been to is Australia, so that’s high on my list! While I’m there, I would also love to visit New Zealand both for its natural beauty and to learn more about the recent news that the national government is introducing a budget that prioritizes well- being over economic growth. One economist has likened economic growth to chewing, noting that we eat in order to achieve the state of being well-fed; chewing is merely the means to that end. The real end point, the ultimate purpose, is not to chew—it’s to be healthy and happy. I think there are a lot of questions about how this perspective on a national budget could actually work, and I would love to be closer to the effort so that I could watch it unfold.
