The Confusing Landscape of Gender-Affirming Care for Transgender Medicaid Patients

Transgender is an umbrella term that describes people whose gender expression or identity are different from their sex assigned at birth. Transmasculine, transfeminine, nonbinary, genderqueer, and other gender-diverse individuals occupy the same range of sexual orientations as cisgender individuals (people whose gender expression or identity are congruent with their sex assigned at birth). However, disparities in access to care and experiences of care in the Lesbian, Gay, Bisexual, and Transgender (LGBT) community are often lumped together in homogenous issue briefs and research studies. The conflation of the two is deeply rooted in politics, policy, and advocacy, but to truly eliminate health disparities it is important to disentangle the issues distinct to gender identity. Many people who are transgender have a unique need to specific medical treatments that will have meaningful short-term and long-term implications for their physical and/or mental health. An obvious corollary isn’t found for sexual minorities. Gender-affirming care, when medically indicated, is the standard of care recommended by leading medical professional organizations and has been associated with meaningful improvements in mental health and well-being. Medically necessary gender-affirming care may include hormone therapy, puberty blockers, surgical procedures, and other forms of treatment. Like any other type of medical care, insurance coverage is a necessary, if not sufficient, factor for most people in accessing care.

The Medicaid program serves America’s most vulnerable populations. Because of structural bias and discrimination and the impacts of poverty, transgender Medicaid enrollees are at higher risk for poor health outcomes. Being unable to “pass” as one’s identified gender heightens this risk and yet low-income transgender Medicaid enrollees, by definition, do not have the resources to pay for gender-affirming care out of pocket.

It is difficult to say how many Medicaid enrollees identify as LGBT because sexual orientation and gender identity are not routinely assessed during enrollment, when most demographic information is collected. It has been estimated that approximately 1.2 million LGBT adults are enrolled in Medicaid, with about 12.7%, or 152,000, identifying as transgender. This may be a significant undercount of younger transgender enrollees, as more current national data indicates the percentage of youth identifying as transgender has almost doubled in recent years.

A recent study found that gender-affirming hormone therapy (GAHT) is covered by Medicaid in 34 states, and gender-affirming surgery (GAS) is covered in 25 states. As the scope of approved gender-affirming services in these Medicaid programs varies, so does the pathway to inclusion. For example, Oregon has relied on the Health Evidence Review Commission to determine coverage guidelines, as it does for all other types of medical care. Other states started offering gender-affirming care in Medicaid following successful lawsuits from enrollees who were denied care (e.g., Alaska and inclusion of “cosmetic procedures” in New York). Many state Medicaid programs and governors have interpreted Section 1557 of the Patient Protection and Affordable Care Act, which prohibits discrimination based on race, color, national origin, age, disability, or sex in covered health programs or activities, to include gender identity and sexual orientation. These states tended to be early adopters of Medicaid coverage (2014-2015) and have routinely issued updated guidance in an effort to reduce access barriers (e.g., Washington).

At least six state Medicaid programs explicitly exclude gender-affirming care (e.g., Texas, Tennessee), but in some of these states policymakers do not seem to be enforcing the ban (e.g., Wyoming, Ohio). Importantly, a significant number of states (estimated at 16) have no stated policies of inclusion or exclusion. Researchers studying the topic were unable to confirm, even after placing a number of inquiries to the Medicaid programs, whether hormone therapy was covered in eight states and gender-affirming surgery in four states. When Medicaid coverage is ambiguous, some Medicaid enrollees have been able to access gender-affirming care by petitioning their Medicaid managed care plan, and some Medicaid managed care plans explicitly cover gender affirming care when the Medicaid program does not. The Transgender Legal Defense & Education Fund maintains a database of Medicaid regulations and guidance related to gender-affirming care, as does the LGBT Movement Advancement Project, but this doesn’t help enrollees when it’s unclear what is covered and what isn’t.

It is highly unusual for the Medicaid program to cover or exclude benefits for a specific subpopulation, particularly those deemed medically necessary. For example, cisgender Medicaid enrollees may have access to hormone treatments or puberty blockers for a variety of medical conditions that are not available to those with a diagnosis of gender dysphoria. Similarly, many states may cover chest reconstruction surgery following a mastectomy while denying coverage for the same surgery, even if deemed medically necessary, for someone experiencing significant dysphoria.

For some transgender patients, particularly those entering puberty, timeliness of care is of the essence. The consequences of a wrong gender puberty are lifelong and can have enormous downstream health and mental health implications. Navigating insurance companies and identifying in-network gender-affirming providers can be challenging even when coverage is clearly stated on the website or in plan materials. Ambiguity of coverage adds stress and delays treatment.

The transgender population is small, but growing, and not all transgender individuals pursue all gender-affirming medical care. Some states might fear that providing coverage will be prohibitively expensive and strain state budgets. While there are no available data on the costs that states with generous coverage currently incur for gender affirming care, Oregon estimated spending $200,000 per year, an inconsequential amount relative to the state’s Medicaid budget and likely relative to the costs of defending exclusion policies in court. Medicaid policy advising bodies, such as the Medicaid and CHIP Payment and Access Commission (MACPAC), have not examined the issue closely.

The Biden administration has signaled support on multiple occasions for providing gender-affirming care in public programs. Recently, the administration issued a proposed rule that would strengthen Section 1557 of the ACA, “aligning the regulatory requirements with Federal Court opinions to prohibit discrimination on the basis of sex, including sexual orientation and gender identity,” as well as clarify that Section 1557 applies to all health insurance issuers that receive federal money, presumably including Medicaid. However, it remains unclear whether implementing the rule would result in states being notified by the Centers for Medicare and Medicaid Services (CMS) that they are required to offer gender-affirming care. A clear federal stance on the issue seems to be the clearest path forward to align state benefits with accepted standards of care for transgender Medicaid enrollees. Once coverage is guaranteed, further work would be required to ensure network adequacy of gender-affirming providers and to monitor the quality of care received. Until Medicaid prioritizes these steps, state variation in Medicaid coverage for gender-affirming care will continue to exacerbate transgender health disparities observed in low-income populations.

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