Transgender advocates concerned with access to health care, coverage

Andre Wilson began their transition 20 years ago this week. Up to that point, Wilson had lived 43 years as a woman who knew they were really a man.

It was a difficult life filled with stress, frequent migraines and general poor health.

"For all of those 43 years I was an expensive person for my health plan," Wilson said. "I will just say this from an insurance perspective: It makes sense to cover the services that people need to help them be who they are."

Today, Wilson is a community advocate, consultant and educator on transgender health. They participated in a panel Sunday at the National Association of Insurance Commissioners' summer meeting in Seattle.

The panel was sponsored by the NAIC Diversity, Equity and Inclusion Council.

"One of the primary roles of diversity is learning about differences," said Evelyn Boswell, director of the council, "understanding that we all have differences."

Specifically, the panel discussed barriers to transgender and transitional health care. Some of those barriers are from insurance coverage and some are in the form of a lack of medical services. Then there is the legislation being pushed in many states to deny transgender services.

Wilson was fortunate to have a supportive family and the financial means to find his true self through a successful gender transition.

"When we have access to services as a community, we see people blossoming, skyrocketing into health, into life, into all of the things that they could not do," Wilson said. "I know people who could not leave the house to go get a job because they did not have a self to present to the world."

Past access to transgender care

Transgender care wasn't always a front-page controversy. In fact, care was readily available and covered by insurance, especially through Medicaid, as far back as the 1970s, said Kellan Baker, executive director and chief learning officer of the Whitman-Walker Institute.

"There were a number of Medicaid court cases in the 1970s where judges found that gender-affirming care for transgender people could not, by the wildest stretch of imagination, be considered cosmetic," Baker said. "Gender is important to all of us. It's important to transgender people ... and the courts recognized that and said, 'You know what? There needs to be insurance coverage.'"

Access to transgender care declined significantly during the 1980s and 1990s, he added. There were "a number of reasons" for the reversal, Baker noted, adding that it, "parallels a lot of what we're seeing now. Efforts to claim that care for transgender people is not medically necessary. Efforts to claim that transgender people don't belong in public spaces."

A second reversal took place around 2006, Baker explained, when several states, led by California, began considering gender-affirming care as medically necessary and essential.

"There's now a clear consensus, in a number of states at least, that gender-affirming care for transgender people is medically necessary and needs to be covered," Baker said.

That brings us to the present, with transgender services being targeted by laws in several states.

"We've seen 20 states ban at least some transition-related care for minors," said C.P. Hoffman, senior policy advisor for the National Center for Transgender Equality. "We've also seen states across the country move to restrict access to Medicaid coverage of transition-related care, not just for minors, but also for adults."

Many of the most restrictive proposals failed to pass, Hoffman said, but transgender advocates expect them to return when new legislatures are seated in January. In the courts, the transgender advocates won either preliminary or final injunctions against restrictive laws "in almost every case," Hoffman said.

One exception is Tennessee, where last month a panel of the Sixth Circuit Court of Appeals accepted a request by Tennessee’s attorney general to lift an injunction issued by a lower court blocking enforcement of the state’s ban on gender-affirming care for transgender youth. The law took effect immediately.

But Hoffman remains hopeful that it will be overturned eventually, noting that the decision language was very soft.

"[Judges] were much more reluctant than you often see in appellate decisions," Hoffman said.

Care available in Washington

Claire Verity is market president for Regence Blue Shield, which counts 2.1 million members in Washington state. The health care system recognizes that different members have different needs, she said, but there are other hurdles to meeting those needs.

"We had access issues before the pandemic," Verity said. "Those issues have exacerbated post-pandemic as far as access to different types of practices."

Regence is working to recruit in those hard-to-find areas of care practitioners, she said. Transgender benefits are determined by following the Professional Association for Transgender Health guidelines, Verity added. Regence does not limit recommended preventive services, a concern of other panelists.

"We are trying to make sure that we listen and that we create that type of benefit structure that opens access and doesn't close it," Verity said.

Clarification: This article has been updated to reflect that Wilson uses the pronouns "they" and "them."

Senior Editor John Hilton covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.

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InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.