The 45th president’s recent tweets banning transgender people from serving in the military because of their potential medical costs underscores the difficulties the transgender community faces in accessing quality health care. They often face stigma and discrimination by health professionals, and even if they have insurance, they may not have coverage for gender affirming procedures like hormone replacement therapy (HRT) or sex affirming surgery (SAS).
On some insurance plans, including Maryland Medicaid, prior authorization is required for someone who is transgender to receive HRT or SAS. Prior authorization is typically used to confirm that extraordinary requests are medically necessary, like transplants or cosmetic surgery. The transgender community shouldn’t have to ask permission and submit claims before receiving life-affirming care.
According to the World Professional Association for Transgender Health, the standards of care for the transgender community include psychotherapy, HRT, changes in gender expression and SAS. Individuals may choose to use all, some or none of these in their health management of gender expression. These are particular therapeutic needs for this population. Although there may be some overlap with cisgender people (those whose personal gender identity corresponds with their birth sex) — like psychotherapy, prostate exams and mammograms — it is unethical to require preauthorization for other care that is specific to a community because it is different from the majority.
Currently the Affordable Care Act does not exclude the transgender population from some medically necessary care based on gender identity. This means a man can get insurance coverage for a pap smear, but not HRT. The language in the act is ciscentric, and wasn’t specific enough to make insurance companies provide coverage for HRT and SAS. Even the quality metrics Maryland uses for its insurance plans do not include sexual orientation and gender identity information. So people in the community who are shopping for private insurance have no way of knowing if their care is covered in benefit plans. Transgender people have not been given a seat at the table in health care decision-making.
Fortunately, as a state, we can shift insurance coverage to include transgender specific care — starting with Medicaid. Coverage under Medicaid would give the most vulnerable population access to quality care: 26 percent of the transgender population lives under the federal poverty line ($12,060 for individuals per year). Poverty in this community leaves people susceptible to violence, drug abuse and depression. Providing this population with access to life affirming care through Medicaid would set an example for private insurance plans to start allowing trans-specific health coverage.
This small step toward transgender insurance parity under Medicaid offers huge opportunities for the community in the health care field and beyond. There would be more understanding of hormone therapy and its side effects, long-term effects and dosing. Visibility in the health care arena can transition bias and discrimination among providers to compassion and understanding. Shifts in provider perception will result in the quality care needed to address the mental illnesses, housing instability and drug abuse that runs in the community. The increased demand to address those needs could transform into a specialized field of transgender health. The possibilities are endless.
California already mandates insurance coverage for life-affirming care in the transgender community. No significant changes were made to their budget for the accommodation, and insurance surcharges on private insurances were actually dropped because there was no significant cost for adding trans-specific care to their benefits.
Every year the transgender community becomes more and more visible; we are doing them a great disservice by ignoring their needs for health care specific to their community. We can take these steps of social progress and apply it on a national level and provide access to quality health care to all Americans.
Chigo Oguh (firstname.lastname@example.org) is a graduate student at the University of Maryland, Baltimore.