This article was produced as a project for the USC Annenberg Center for Health Journalism’s 2026 National Fellowship Dennis A. Hunt Fund for Health Journalism. It’s part of a series on LGBTQ+ health in rural areas.
LGBTQ+ people don’t just need friendly, informed providers—they may also need specialty care that is often a rarity in rural areas.
“When I started hormone replacement therapy, I originally wanted to go to an endocrinologist,” said Anthony Wolf, a nonbinary South Lake Tahoe resident who chose to go by their legal name for this story. “But I wasn’t aware Barton Hospital didn’t even have one. I assumed they would have everything as the biggest hospital in town.”
Instead, Wolf now drives a nearly four-hour, 188-mile round trip to get bloodwork done and hormones prescribed at Planned Parenthood in Roseville.
The Tribune conducted a survey of 15 LGBTQ+ people across the Tahoe Basin and interviewed dozens of patients and healthcare experts. Over 60% of respondents answering the Tribune’s survey said they leave the Tahoe-Truckee area to get healthcare, going as far as Reno, Las Vegas, San Francisco, Los Angeles and Houston to receive care. 70% of those respondents said it was to find specialty healthcare they believe they wouldn’t receive in the Lake Tahoe area, such as gender-affirming treatments, voice training or sexual health testing.
Traveling for care
Data from the 2017 National Household Travel Survey showed that rural residents in the West traveled an average of 22.7 miles per trip—the highest mileage compared to other regions in the United States. For rural, mountainous areas like Tahoe and Truckee, both distance and terrain can make it hard to access care.
Increased travel burdens negatively impact health, and in particular, access to specialists accounts for 55% of a difference in preventable hospitalizations and 40% of a difference for mortality when comparing rural and urban patients.
Dr. Karen Thiele, a family physician in Reno, Nevada, said she has patients from Lake Tahoe drive an hour or more to get care from her, as well as from the surrounding rural areas. “I personally do not travel to rural areas, so they end up traveling to me.”
Barton’s chief medical officer Dr. Kandra Yee wrote to the Tribune that referrals to other locations are “a common practice to ensure patients receive specialty care in health systems more experienced and equipped to meet those needs.” But patients sometimes find themselves having to travel hours away to get to specialists, even for what’s considered more routine specialist care like GI, dermatology or podiatry.
Although some South Lake Tahoe residents have considered transferring their care to Tahoe Forest Health System, also called TFHS, they might not find the specialists they need there either. While Barton serves the rural area, it doesn’t have the same designation as TFHS—a critical access hospital. That designation, provided by the federal government, helps rural health providers offer core services, but focuses on emergency and inpatient care, not necessarily specialists.
The privilege to travel
Traveling to care in the Tahoe-Truckee area often requires being able to drive your own car, given the winding, mountainous roads and the still growing public transit options in the area. And in the past year, services like the South Lake Tahoe Cancer League’s transport to cancer-related care facilities in the area has ceased.
TFHS offers some specialists that aren’t available at Barton, like endocrinology—a motivating factor for transgender residents around the Tahoe Basin to switch their care to the system, even if it means an hour-long drive.
But for others, the travel just isn’t worth it. Zephyr Kao, a Tahoe resident, recounted their experience when they moved to Tahoe and began seeking care. “What drove my care was my changing insurance, so I was looking for care in-network. But I wasn’t trying to go out to Reno. Ideally, you want a provider that knows your history and records, specific answers that fit your life, body and physical attributes, and to refer you with all your records.”
I don’t want to drive down to Reno for routine testing. I just don’t,” said Mack, who lives in Truckee. “If that was the case for me, I likely just wouldn’t get care. I want my doctors up here to know how to take care of me.”
Kao, Mack and others expressed distrust of their doctors. But they were part of the minority 26% that stayed in Tahoe and Truckee to get their care. The other 74% of respondents said they were willing to travel much farther. The median total commute time for LGBTQ+ responsive care was 4 hours or more.
Dr. Thiele said that online options can provide education to rural hospitals, such as through Project ECHO, which offers continuing education from specialists and a network of experts and peers to undeserved communities. In the same vein, Thiele said that many opt for telehealth to find options that work for them, even if they’re not local.
Wolf recognizes that telehealth might not be the right fit for others because it didn’t work for them. They also recognize that it’s a privilege to travel.
“I’m lucky that I can commute that far, I’m lucky I can drive. Not everyone can do that,” said Wolf. “You weigh options and the cost of driving, the price of gas, versus the cost of local healthcare. Honestly, I have paid what would be a life-ruining amount of money for others so I could get care.” Half of respondents who got healthcare outside the area said cost was a factor and that Tahoe-Truckee’s local healthcare was more expensive.
The costs are not cheap. But Wolf’s bloodwork at Barton cost $400, and the cost of a drive and visit to Planned Parenthood for hormones is four times cheaper for them.
Sexual health
The high rates of infection and death among gay men and transgender people during the HIV/AIDS crisis has left an indelible mark on the LGBTQ+ community in the United States. One of those came in the form of the name: gay activists were the ones who proposed changing it from GRID (gay-related immune deficiency) to AIDS to reduce stigma around its association with gay people.
During that time, the government failed to provide funding or support for research and treatment of AIDS, and hospitals and healthcare workers often turned away those suffering from the disease—one of the few groups who did care for AIDS patients were lesbian nurses. The overt discrimination and homophobia from institutions resulted in a political turning point, with LGBTQ+ led activist groups like ACT UP (AIDS Coalition to Unleash Power) being formed in response.
“Health is really important to the queer community, and especially gay men,” said Sam Grossberg. “The way our community was treated during the AIDS crisis is generational knowledge that impacts gay men today.”
Grossberg said he was surprised and concerned that when he wanted to get sexual health testing in TFHS, his friends warned him that TFHS did not offer them rectal swab testing. “It was astonishing to me because there’s an expectation it should be offered and covered by insurance if you’re on PrEP,” a medication that prevents people from contracting and spreading HIV.
TFHS clarified to the Tribune that they do offer rectal swabs, but did not specify further whether this was part of regular testing.
Grossberg said when it comes to health issues specific to his experience as a gay man, he still reaches out to his doctor in San Francisco rather than local doctors, especially due to the long wait times to get a primary care provider in Truckee. “I don’t expect Truckee to be as good as San Francisco, but I feel like we can do better,” he said.
An Hoang, another gay man in Truckee, agreed there was a lack of cultural knowledge, which he experienced during his own experience trying to get PrEP. He said that because in-person care was important to him, he was willing to drive elsewhere to get care.
Hoang and others said they preferred to go to Reno or another clinic to get sexual health testing, motivated by better prices and knowledge of how to handle insurance.
Insurance issues
While getting treated with PrEP, both California and Nevada have access programs that will help cover PrEP, which often comes with regular sexual health testing. However, if care facilities don’t know how to bill your insurance, there can be huge bills that come in the mail.
“I think it absolutely is a barrier to access,” said David Mack, a gay man in Truckee and founder of Truckee Pride. “Seeing a huge $900 bill when you’re not expecting to pay anything scares people away from getting treatment.”
Hoang said that gay friends of his in the area had to learn the healthcare system and how to navigate the medical codes for PrEP prescriptions to get insurance coverage. “That’s the kind of knowledge that is not there in these systems, because they’re not prepared for LGBTQ+ people to ask for regular STD testing for PrEP.”
Jasen Brooks, director of identity and cultural engagement and lecturer at the Orvis School of Nursing at the University of Nevada, Reno (UNR), also touched on how billing impacts care. “Billing is so complex: it takes time and experience for a provider to become facile on it. Sometimes the notes for insurance in your chart and not a judgment on you as an individual, but your provider trying to ensue you get care. There’s a real art in it.”
However, Brooks said, it’s not easy to get that kind of education—it’s informal and something you learn through guidance, mentorship and experience, not a course.
40% of respondents to the Tribune and Sun’s survey on LGBTQ+ health said they wanted providers who understood how to bill insurance properly.
Navigating insurance and healthcare systems can be more complex for LGBTQ+ people. According to the Williams Institute, 1.8 million LGBTQ+ adults rely on Medicaid as their primary insurance, and LGBTQ+ adults are twice as likely as non-LGBTQ+ adults to have Medicaid as their primary insurance.
Morgan Williams, a psychiatric emergency services therapist working in the Tahoe area, said that having Medicaid as a primary insurance can pose problems for rural residents. While it may open up the ability to see certain mental healthcare specialists, it can make it challenging to get referred to specialists on the other side of the state border. A patient on Medi-Cal can’t be seen in Nevada for specialists, even if a relevant specialist is 15 minutes away on the other side of the state border.
Williams also pointed out an institutional barrier for transgender Medicaid patients in getting the correct name on their insurance. It requires an amended birth certificate, which takes much more time and effort than a simple legal name change.
For those on other insurance, rural healthcare isn’t much easier. Some workplaces in Tahoe even offer an additional stipend for healthcare, because there are fewer providers that take typical workplace insurance, primarily if their main offices are located outside of Tahoe.
Williams had top surgery before moving to Tahoe, and many trans people seeking gender-affirming surgeries spend years researching their doctors and their techniques. “The expertise from my doctor in Los Angeles, who was knowledgeable about my surgery, the care, and how to bill insurance, was really helpful for me in even deciding to get the surgery,” they said.
Both Williams themselves and their patients spoke about concern with not having specialists in the area and traveling away to get care, especially for complex medical procedures.
Recruiting specialists and accessing care
Having specialists who can create positive experiences is the ideal scenario—and not impossible in Tahoe. Laurie Kemper, who has lived in Tahoe for over forty years, said she has been lucky in the treatment for her health issues, praising the early referral to a specialist in Carson Tahoe and cultural sensitivity from her Barton OB/Gyn, who expressed support in finding a surrogate for her after she came out.
However, she recognizes that her insurance was better than most and made it possible for her to access certain specialists. But better insurance doesn’t guarantee an endocrinologist visit when there are none nearby.
“When you live in a rural town, your resources are already stressed,” said Kao. “You need more incentives for doctors to live and work here.”
“Gone are the days of the town doctor who can afford to stay around,” said Brooks. From the healthcare education side, he also recognized that the costs of healthcare education can also limit the ability for doctors to specialize.
And while recruitment and higher education are important, rural doctors have their strengths too. Williams says that rural providers often become specialists and experts in the issues their community deal with. They believe it would improve the quality of care if rural providers were given resources to understand more, like injection training equipment or regularly updated training for gender-affirming care.
Dr. Thiele, who trains residents, said she was gifted a mug that encapsulates her mantra on caring for patients: “You don’t need to refer that out.” While it was common practice before to refer patients seeking hormone therapy to endocrinologists, Thiele says that these days, average primary care physicians are familiar with the medications used, since they have a wide variety of applications—not just hormone therapy.
“Primary care really needs to take care of all their patients and all their concerns, and that includes gender-affirming care,” said Thiele. She added that while much of the effort to make these changes would be self-propelled, that there was resources like Project ECHO and Fenway Health for providers to become better educated in this care, even when there aren’t available specialists locally.
For now though, patients still experience the burden of travel.
“The length of the drive is extremely inconvenient,” said Wolf of their 188-mile trip. “Some solutions to this are more complicated than others, but there’s gotta be something they can do.”
In a time that’s more hostile to LGBTQ+ people, mental health outcomes for the community suffer. How do politics and policies play into mental health care in rural communities, which are historically underserved? Read more in part three of this reporting project on LGBTQ+ health in Tahoe, scheduled to publish in next week’s edition of the Tahoe Daily Tribune.
