Transition Coverage and Clarity in Self-Insured Corporate Health Insurance Benefit Plans

Navigating payment and policy barriers to gender-affirming care for transmasculine individuals: A qualitative study and policy assessment

Over the past decade, access to and insurance coverage for gender-affirming medical and surgical treatment for transgender (trans) individuals in the U.S. has improved. Despite this, trans individuals continue to experience insurance-related barriers to gender-affirming care (GAC)-and in particular, transmasculine individuals may face gender-specific barriers resulting from regulations on masculinizing hormones. In this study, we interviewed transmasculine individuals from across the U.S. about their gender-affirming care experiences with a focus on insurance, payment and policy-related barriers to care. Interviews were conducted via video-conferencing software, analyzed using a codebook approach to thematic analysis, and contextualized within a broader analysis of the policy landscape dictating coverage for gender-affirming care. Participants reported insurance denials for gender-affirming care, as well as challenges with prior-authorization requirements, letter requirements, restrictive formulary lists and other challenges that complicated and/or barred access to care. Many discussed adaptive strategies to these challenges, which included utilizing community resources and knowledge, as well as receiving material support from family, friends, and partners, and developing technical and interpersonal savvy skills in response to insurance challenges. Participants expressed a range of emotional responses with regard to payment and related challenges, from annoyance and frustration to hopelessness. Our findings illuminate the persisting challenges that transmasculine individuals face when attempting to access and pay for gender-affirming care, despite improvements in insurance coverage and legal protections in recent years resulting from the Bostock ruling by the Supreme Court and the expansion of the ACA's Section 1557.

United States Health Policies on Gender-Affirming Care in 2022

BACKGROUND

Within the United States, access to gender-affirming operations covered by health insurance has increased dramatically over the past decade. However, the perpetually changing landscape and inconsistencies of individual state health policies governing private and public insurance coverage present a lack of clarity for reconstructive surgeons and other physicians attempting to provide gender-affirming care. This work systematically reviewed the current U.S. health policies for both private insurance and Medicaid on a state-by-state basis.

METHODS

Individual state health policies in effect as of August of 2022 on gender-affirming care were reviewed using the LexisNexis legal database, state legislature publications, and Medicaid manuals. Primary outcomes were categorization of policies as protective, restrictive, or unclear for each state. Secondary outcomes included analyses of demographics covered by current health policies and geographic differences.

RESULTS

Protective state-level health policies related to gender-affirming care were present in approximately half of the nation for both private insurance (49.0%) and Medicaid (52.9%). Explicitly restrictive policies were found in 5.9% and 17.6% of states for private insurance and Medicaid, respectively. Regionally, the Northeast and West had the highest rates of protective policies, whereas the Midwest and South had the highest rates of restrictive policies on gender-affirming care.

CONCLUSIONS

State-level health policies on gender-affirming care vary significantly across the United States with regional associations. Clarity in the current and evolving state-specific health policies governing gender-affirming care is essential for surgeons and physicians caring for transgender and gender-diverse individuals.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.

Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the US

Importance

Genital gender-affirming surgery (GAS) is safe and offers substantial benefits to patients. Geographic accessibility and high out-of-pocket (OOP) costs reportedly hinder access; however, to date, this has not been thoroughly investigated at the national level.

Objective

To estimate OOP and total costs for GAS among commercially insured beneficiaries and assess whether costs differed between surgical procedures conducted in and outside the patient's state of residence.

Design, Setting, and Participants

This cross-sectional study used previously collected insurance data from the MarketScan Commercial Database (129 million patients) from January 1, 2007, to December 31, 2019. Vaginoplasties and phalloplasties were identified using diagnosis and procedure codes among patients aged 18 to 64 years. Out-of-state surgical procedures were identified based on residence at enrollment and place of service of the surgery. Data analysis took place from July 1 to September 31, 2021.

Exposures

Vaginoplasty and phalloplasty.

Main Outcomes and Measures

The main outcomes were differences in OOP and total costs by out-of-state designation, census region, age, and insurance type for surgical procedures, estimated using multivariable linear regression models.

Results

The study included 771 patients who underwent GAS. A total of 609 underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside their state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, of 39.7 [11.6] years) and 81 (50%) underwent surgery outside their state (mean [SD] age, 35.8 [10.9] years); 20 vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in or out of state owing to missing data about the facility or residence. Procedures outside the state were associated with 49% (95% CI, 19%-85%) higher OOP costs compared with procedures done in the state of residence.

Conclusions and Relevance

In this cross-sectional study, 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty underwent the procedure outside their state of residence. Patients who underwent these procedures outside their state also experienced higher OOP costs than did those who underwent these procedures in their state. Improving geographic access and understanding patient preferences for surgical care may help reduce the cost burden for those planning to undergo GAS.

Health and health care access in the US transgender population health (TransPop) survey

BACKGROUND

Probability and nonprobability-based studies of US transgender persons identify different disparities in health and health care access.

OBJECTIVES

We used TransPop, the first US national probability survey of transgender persons, to describe and compare measures of health and health access among transgender, nonbinary, and cisgender participants. We directly compared the results with 2015 US Transgender Survey (USTS) data and with previously published analyses from the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

All participants were screened by Gallup Inc., which recruited a probability sample of US adults. Transgender people were identified using a two-step screening process. Eligible participants completed self-administered questionnaires (transgender n = 274, cisgender n = 1162). We obtained weighted proportions/means, then tested for differences between gender groups. Logistic regression was performed to evaluate associations. Bivariate analyses were conducted using the weighted USTS data set for shared variables in USTS and TransPop.

RESULTS

Transgender participants were younger and more racially diverse compared to the cisgender group. Despite equally high insurance coverage, transgender people more often avoided care due to cost concerns. Nonbinary persons were less likely to access transgender-related health care providers/clinics than transgender men and women. Transgender respondents more often rated their health as fair/poor, with more frequently occuring poor physical and mental health days compared to cisgender participants. Health conditions including HIV, emphysema, and ulcer were higher among transgender people. TransPop and USTS, unlike BRFSS-based analyses, showed no differences in health or health access.

DISCUSSION

Transgender persons experience health access disparities centered on avoidance of care due to cost beyond insured status. Health disparities correspond with models of minority stress, with nonbinary persons having distinct health/health access patterns. Despite different sampling methods, USTS and TransPop appear more similar than BRFSS studies regarding health/health access.

CONCLUSION

Future research should elucidate health care costs for transgender and nonbinary people, while addressing methodology in national studies of transgender health.