In 2009, Danni Askini was raising hell to debunk “Gender Identity Disorder” from the official list of diagnosable mental illnesses. It’s not like concepts of disease are immutable, after all: Homosexuality was a sickness until 1973, when doctors suddenly agreed that it’s wasn’t. Why shouldn’t transgender people similarly shed the stigma of pathology?

“Oh, young me,” she laughs to the roughly 60 people packed inside Gay City’s tiny auditorium. “You didn’t know!”

Askini is speaking on a panel held last Saturday at the Trans Health Insurance Forum, orchestrated by the Coalition for Inclusive Healthcare. And she’s laughing because, in the past five years, she’s gone from decrying transgender diagnoses to sometimes promoting them, for two reasons.

First, a shift in what that diagnosis means: in 2013, the American Psychiatric Association updated “Gender Identity Disorder” (which treated gender nonconformity per se as an illness) to “Gender Dysphoria” (which concentrates on the harm caused by dissonance between experienced- vs. assigned-gender). Second, the Affordable Care Act (AKA Obamacare) has expanded insurance coverage and — as the Washington Office of the Insurance Commissioner affirmed this past June — prohibited insurer discrimination against trans-related care.

“A lot of trans people have avoided health insurance for years,” says activist Tobi Hill-Meyer, “because they felt like it wouldn’t make sense to pay into a plan that doesn’t cover your basic needs.”

But now that a Gender Dysphoria diagnosis has become more of a resource and less of a threat to trans people, activists are scrambling for ways to show that trans-related care –from hormones to surgery — is “medically necessary” and therefore covered by health insurance. The stakes are high for transgender people, who face widespread discrimination and have an attempted-suicide rate of 41%. Referring to hormone therapy for trans adolescents, audience member Dr. Linda Gromko says, “This is nothing less than a suicide prevention measure, period.”

Plenty of folks at the Forum have war stories about insurers reflexively denying trans-related claims. One speaker talks about insurers arbitrarily imposing an age-floor of 18. A man in the audience later relates how he was denied chest surgery because, the company claimed, he seemed fine without it.

Emerson Sekins, formerly of the Q Center at UW, recalls a law student at UW who broke her wrist. “Once the insurance company found out that she was trans,” he says, “they ordered her to repay everything.”

“Insurance companies… will find ways to deny you,” adds Askini. The trick, she says, is persistence. “Appeal, appeal, appeal. The worst they can do is say no.” And a history of denials, she says, makes it harder in the future for insurers to wiggle out of class-action lawsuits or inquiries from the state insurance commissioner.

Resources for appeals and other trans health insurance issues can be found at Q Law, which holds a free legal clinic once per month on Capitol Hill; the Ingersoll Gender Center; the Gender Justice League; and We-Are-1.com.