Sara E. Islam
The transgender and gender non-conforming population has long been a marginalized group with significant barriers to medical care. Despite mounting evidence that gender- affirming surgery improves psychological distress and quality of life, these patients still experience difficulty accessing treatment and incur substantial financial burden. This article explores policies influencing access to and coverage of gender-affirming surgeries in the United States and proposes potential solutions to improve the health disparities prevalent in this population.
Roundtable Journal on Health Policy | Volume 5 | Issue 1
About 1.4 million Americans (0.6% of the population) openly identify as transgender (Wiegmann et al., 2021). As this number has increased in recent years, so have the requests for gender-affirming surgical procedures. However, transgender individuals have proved to be one of the most marginalized patient groups in the United States placing them at increased risk for many medical conditions and burdening them with some of the largest barriers to care (Wiegmann et al., 2021). Patients with a diagnosis of gender dysphoria are six times more likely to have had a mood and anxiety disorder health care visit, three times as likely to have received prescriptions of antidepressants and anxiolytics, and six times as likely to have been hospitalized after a suicide attempt when compared to the general population (Dhejne et al., 2011; Bränström & Pachankis, 2020). Comprehensive care of these patients, including mental health counseling, hormone replacement therapy, and gender-affirming surgeries, aim to decrease psychological stress and improve comfort by aligning a patients’ appearance with their gender identity (Bustos et al., 2021). Though the nature of gender-affirming care is multidisciplinary, plastic and reconstructive surgeons play a crucial role in caring for this population. As such, plastic surgeons ultimately share responsibility in patient advocacy, policy, and access to care.
The implementation of the Affordable Care Act in 2010 resulted in expanded insurance coverage through protections given to transgender individuals. The legislation included a nondiscrimination mandate that prohibited discrimination on the basis of sex which extended to health insurance coverage, eligibility determinations, benefit design, and coverage determinations (Wiegmann et al., 2021). Although this increased access to medically necessary gender-affirming surgery, access was not uniformly increased across the country. Currently, coverage of procedures remains in the hands of the states. A few states have laws detailing insurance discrimination protections based on both sexual orientation and gender and some based on either gender or sexual orientation, but most states have no laws offering LGBTQ+ inclusive insurance protections (Movement Advancement Project, 2023). This presents an enormous problem as the greatest barrier to care is cost. Because surgery without insurance is often cost-prohibitive, lack of insurance can cause a delay in care that negatively impacts physical and psychological outcomes (Ngaage et al., 2020). Studies regarding outcomes following gender-affirming surgery are slowly emerging with preliminary data showing improved anxiety, anger, depression, social isolation, global mental health, and quality of life with a significant reduction in mental health treatment following surgery (Caprini et al., 2022; Bränström & Pachankis, 2020). Thus, coverage is an important step in increasing access and preventing negative health outcomes within the transgender population (Ngaage et al., 2019; Wiegmann et al., 2021).
However, access does not solely mean insurance coverage. For example, in Mississippi the only place offering gender-affirming care is the University of Mississippi Medical Center. This large academic institution not only serves the entire state but is also a catchment area for some of the surrounding states. Even at this large institution, they only have one plastic surgeon, and this individual only performs gender-affirming top surgery. Thus, the number of transgender individuals receiving care remains well below the number of individuals who desire it. Patients face barriers related to both physical distance and ability to pay. At the state level, policy has been driven by the values of the politicians and their constituents leading to excellent care in states such as New York while more conservative states such as Mississippi are lacking.
The dearth of standardized treatments across states is reflected by the large variability in the requirements needed for insurance coverage of gender-affirming top and genital, or bottom, surgery. The World Professional Association for Transgender Health (WPATH) provides suggested criteria to providers and insurance companies that are intended to guide standards of care, but adherence to these guidelines has also been variable. Only about 4% of companies follow WPATH criteria and most require additional measures beyond what is recommended (Ngaage et al., 2019). Between insurers, some of the most varied requirements are the minimum age and a unified definition of what constitutes gender dysphoria (Ngaage et al., 2020). Perhaps the most frequent, arbitrary barrier to coverage is proof of legal name change which has been found to be required by 1 in 5 insurance companies (Ngaage et al., 2020). Though insurers cannot deny transgender patients services they otherwise cover for cisgender patients, they can refuse coverage for procedures considered to be cosmetic (Wiegmann et al., 2021).
At the physician level, there is a distinct lack of knowledge on transition-related services. Additional training and resources need to be provided to medical professionals of all specialties to achieve the level of care transgender individuals rightly deserve. Another distinct area for improvement lies in transgender-specific research itself. Currently, there is a paucity of transgender-specific academic literature which brings its own challenges. Though the benefits to overall patient health have been well-documented, other metrics proving the benefits of gender-affirming surgery are only just emerging. Previous research has been limited by nonrepresentative sampling, short follow-up periods, and self-reported measurements often using survey tools that have yet to be validated (Bustos et al., 2021; Bränström & Pachankis, 2020). If an overall reduction in healthcare utilization can be proven in long-term, prospective, longitudinal studies, then a strong case can be made to insurance companies that up-front payments for surgery will reduce long-term costs. The Center of Medicare and Medicaid Services has deemed the clinical evidence inconclusive and as such has not issued a national coverage determination on gender reassignment surgery for Medicare beneficiaries (Ngaage et al., 2020). While a paucity of research is cited as the reason coverage is not provided, the absence of coverage is a barrier to patients seeking care and thus prevents the collection of clinical data. It has locked forward progression into a stalemate and prevented both policy and practice from undergoing necessary reform.
This begs the question, what can plastic surgeons do to improve care and advocate for their transgender patients? Stream-lining insurance authorization requirements and increasing insurance coverage transparency are lofty goals that would have a huge impact. Though coverage improved with the implementation of the Affordable Care Act, challenges still exist as many people remain uninsured or on commercial insurance plans that offer only limited coverage. Reimbursement is further complicated by surgeries that are considered cosmetic in cisgender patients as opposed to medically necessary. Like many aspects of the U.S. healthcare system, improved access and reduced financial burden would be seen with increased federal regulation. However, the political climate is not conducive to further socialization of medicine and so the policies surrounding the rights of transgender individuals remains in the hands of the states.
Moving forward, patient advocacy should be the main goal with increased educational materials, participation in lobbying for increased patient rights, and increased equity of care. Plastic surgeons can also contribute to transgender-specific research; hopefully to provide the necessary evidence to increase insurance coverage and appeal to politicians to expand protective policies. Once a substantial body of literature on the benefits of gender-affirming care is established, additional legislation, backed by concrete evidence, can be passed. Recently, a fellowship in gender-affirmation surgery has been added to the mix. The hope is that as more plastic surgeons graduate from these programs, the availability of comprehensive gender-affirming surgical procedures will also increase. As the field of gender-affirmation continues to grow, plastic surgeons have an opportunity to participate in research, education, and advocacy for their patients.
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