Background
For individuals who are transgender or gender diverse (TGD), gender-affirming care (GAC) can be essential for their physical and mental wellness. While GAC may include hormone therapy and surgery, GAC also includes mental healthcare, assistance with legal documents, and respecting pronoun and name changes, among other things. Major national and international medical and psychiatric associations have established guidelines supporting the use of GAC for TGD individuals. Unfortunately, GAC can be expensive. Gender-affirming hormone therapy can cost as much as $3,792 annually and gender-affirming surgery can range from $53,645 and $133,911. Given these high prices, health insurance is essential to help make GAC affordable and accessible.
Cost-Related Barriers
Compared to cisgender adults, TGD adults are more likely to report cost-related barriers to care and are more likely to have unmet health needs, exacerbating the need for affordable access to GAC. Of the 1.3 million transgender adults in the United States, 276,000 are enrolled in Medicaid. TGD Medicaid recipients are less likely to report being in good health and more likely to report serious mental distress than cisgender recipients. In addition, TGD adults on Medicaid report being denied coverage for hormone therapy (29%), gender-affirming surgery (56%), and gender-specific health care including preventive care (11%). Without access to insurance coverage for their treatment, the costs of gender-affirming care can prevent Medicaid beneficiaries from getting the medical care they need. For example, 37% of TGD Medicaid beneficiaries reported not going to a doctor because of cost, compared to only 27% of those who are privately insured.
State Action and Inaction
As of 2022, 31 states allow Medicaid beneficiaries to obtain some form of GAC, but despite opposition from leading medical groups, many states continue to restrict access to GAC. Several states, including Texas and Florida, have prohibited Medicaid coverage for GAC, leaving 38,000 individuals without care. An additional 17 states have yet to address coverage, leaving the status of 74,000 beneficiaries’ access to care uncertain.
Additionally, there are currently more than 80 bills that have been introduced in 27 state legislatures that reduce TGD individuals’ access to care. Texas, Oklahoma, Florida, and South Carolina recently introduced bills prohibiting taxpayer funding for gender-affirming hormones or surgery. However, a similar bill was deemed unconstitutional in West Virginia in 2022. Tennessee lawmakers have introduced a bill that would ban private insurance companies that offer GAC in other states from providing Medicaid coverage in Tennessee - even if they do not cover gender-affirming care in the state. Alternatively, states like Maryland have recently moved to protect public funding for gender-affirming care. Legislation has been introduced in the U.S. House of Representatives that would prohibit the use of federal funds for GAC. The ever-changing landscape regarding Medicaid beneficiaries’ access to gender-affirming care is further complicated by a lack of federal protections for TGD individuals. It is yet to be seen how the courts or federal government will respond to these restrictions of care.