Not all trans women find this surgery necessary. I do. Living with the feeling that it was out of reach has been a source of despair that has lived in the back of my mind for decades.

This year has been deeply challenging and fully transformative for me and, as a result, I’ve never felt more settled in my skin. I’ve never felt this at home, this unconflicted in my body. Is this how you feel every day? Do you feel mostly at home in your body? It’s going to take me a while to get adjusted to this. If you’ve always felt settled in your skin, you’re really lucky.

The first time I tried to buy my own insurance as a freelancer, several bubbles and wars ago, I was denied coverage. I was a 20-something vegetarian coastal Californian who walked everywhere and had no documented medical conditions other than being trans. I was making an embarrassingly moderate amount of money during the “dot com boom” and could certainly afford said insurance company’s policy. But they dismissed me, leaving me with a year-long debt to pay back thanks to a good-faith premium I’d already forked over.

The thing about trans medical care is that it’s expensive. There still aren’t that many medical professionals out there from which we can choose. Historically, all insurance companies specifically denied coverage for transition-related costs in the fine print.

It was usually listed pretty high up in the fine print too; they wanted you to know right away that NO WAY were they going to consider paying for that shrink, or that electrologist, or that endocrinologist, and certainly not that out-of-state surgeon. Suck it up, buttercup, they said. We’re not here to help you.

Let this settle in: I couldn’t even pay for a policy that would cover me for care unrelated to a gender transition. My takeaway? Because gender transition is so pervasive, any health care I receive could be classified as such, and so there’s plausible deniability baked into the fine print, and any underwriter could kick me to the curb over ulcers, or asthma, or diabetes, or multiple sclerosis, or HIV.

Silly me, I tried to give them money anyway, and they wouldn’t take it.

The ACA, in combination with policy changes by my insurer, has rejuvenated me; it has provided me a great deal of hope for the future. I am so grateful for this hopeful spark; it’s been this thing more than any other that has kept me from falling into complete despair these last weeks. I want to share what I’ve learned. I want those of us who, like myself, had largely given up on the idea that we’d ever be able to access this sort of care, to discover what it’s like to feel like their place in the world makes sense. I want those of us who need gender confirmation surgeries to receive them before their self-worth is obliterated.

I’m a lucky one, to be sure. I needed the ACA and the policies that came in its wake. It’s arguably prolonged my life. It’s obviously imperfect, but it’s necessary. It’s hard for me not to assume that those who would repeal the ACA right here and now would rather I be dead, and that bums me out. It’s hard for this optimist to keep the glass half full when they keep shattering the glasses.

Rahne Alexander is a video artist, musician and performer. Her film and video art has been screened in galleries and festivals across the country, including the Baltimore Museum of Art, MIX (NYC), Freewaves (LA), Homoscope (Austin) and Cinekink (NYC) and she is an alumna of the Experimental Television Center residency program. Rahne was featured in the 2010 documentary feature Riot Acts: Flaunting Gender Deviance in Music Performance, and she performs frequently with several bands, including Guided By Wire and The Degenerettes. She is a former curator/organizer of Baltimore's avant-garde Transmodern Festival and the long-running, award-winning queer cabaret Charm City Kitty Club. For five years, 2011-2015, Rahne was in charge of operations and development for the Maryland Film Festival. Read more about her incredible work here.