Why isn’t Obamacare fully covering transition services?

Transition looks different for every trans person, but for those who do choose to pursue medical transition (or want to), there’s one thing that it definitely looks like across the board: Expensive. Depending on what kind of transition services people want, they may be looking at hormones (a life-long commitment in many cases), gender confirmation surgery (top and/or bottom surgeries), various cosmetic procedures, therapy, and a slew of other costs. Addressing the mental health need of making sure that your body aligns with your perception of gender is an expensive proposition.

It’s one reason transition has been medicalised, creating both a standard of care and a framework for ensuring that people can access that care. My insurance company requires a diagnosis of gender dysphoria to provide and cover transition services, but the care providers qualified to offer it don’t view it as a medicalised gatekeeping test: They address people of a variety of genders and the diagnosis is a pro forma need designed to make sure people are eligible for transition. While it is a form of medical gatekeeping that pathologises my gender, members of the gender clinic work very hard to make sure people don’t feel that way.

My health care provider covers many of transition-associated expenses, lowering the costs of things like surgery considerably by treating them like ordinary outpatient (or inpatient, as the case may be) procedures — also, notably, not as ‘voluntary’ procedures that might have a higher copay. In other words, my provider acknowledges medical transition services as a health care priority and necessity.

The same doesn’t hold true for many HMOs and other health care providers. Unless required to do so by law or contract (as in some cities or with some companies), many insurance companies will not cover transition services, or have a very high share of cost — one that can be prohibitive when we’re talking about surgeries that can run into tens of thousands of dollars. This even though the trans population is relatively small, and the population of those pursuing transition even smaller, so we hardly represent a significant insurance risk and we don’t create a danger to the risk pool. Believe me, if transition care is fully covered, everyone and their sister won’t be running out to sign up for it. It’s a specialised health care need.

Earlier this year, the Department of Health and Human Services proposed a new rule clarifying the status of transgender patients under Obamacare with the intention of banning discrimination — a historic issue for many of us (for example, a man might be denied treatment for ovarian cancer). The rule includes a number of clauses, many of which are very important, but one thing it stops short of doing is actually requiring that insurance providers cover transition services, full stop. It does indicate that if someone is diagnosed with gender dysphoria and cleared for surgery by health care providers, the insurer must provide compelling evidence to deny a medically indicated procedure (like hysterectomy), but that’s not the same thing as requiring full coverage, end of discussion. It also doesn’t mean that they need to do so affordably.

Approaches to transgender care vary widely in the United States. I’m fortunate enough to live in the Bay Area, where there’s an advanced understanding of gender and transness, and it never for a second occurred to me that I wouldn’t get necessary care. I knew that a diagnosis was a tickbox on some paperwork that a counselor had to fill out after meeting with me, not something I would be required to dance through endless hoops to access, acting like a performing pony the whole time. The Benjamin Standards — thankfully disappearing in most places — are basically nonexistent here. Other trans people, especially nonbinary people, live in regions where a diagnosis — what they need to obtain care — is at the mercy of a health care provider who may not be sympathetic to trans needs or experienced with trans patients. What to me was a tickbox dispensed with at my first meeting with a therapist is for others an insurmountable barrier, a devastating side effect of the medicalisation of transness.

Many transgender people in the United States are low income, and they face significant job discrimination. Consequently, many have limited health care plans and do not have insurance through their employers — or if they do, it’s not top of the line. Generally speaking, transgender patients who want to be able to afford transition care without bankrupting themselves need Platinum (‘Cadillac’) insurance coverage, which isn’t accessible to many people. Consequently, instead they have to live with extreme dysphoria. They can’t afford to seek out care providers who will work with their needs, and they can’t afford to spend thousands or tens of thousands of dollars — a new vagina ain’t cheap — on surgeries.

Obamacare should be providing transition care like it covers contraception and basic preventative care, as a service that is free of charge to all eligible people — in other words, to all human beings. Free vaginas for all. Free penises for all. Free deboobulation — or breast enhancement — for all. Free hormones for all. Free tracheal shaving for all. Transition is a right, not a privilege, and finances should never be an obstacle to the level of transition care that someone needs. Ever.