Mississippi Medicaid spent a tiny fraction of its budget on gender-affirming care before lawmakers banned it

The Mississippi Division of Medicaid spent months working to determine how much it paid in claims associated with gender identity disorder or gender dysphoria following an anonymous legislative request, according to emails obtained through a public records request.

The answer: A maximum of $58,900.82 in taxpayer money over the last five years from the agency's annual budget of $6 billion – nearly half of which paid for a mastectomy to treat a "life-threatening disease" that was not gender dysphoria. No money was paid to providers for intersex surgery for trans men or trans women.

Attorneys for Medicaid initially miscalculated the answer, but after many back and forths over email with a representative from a legislative committee, landed on this imperfect estimate.

It is unclear from the documents how much Medicaid paid in reimbursements specifically for gender-affirming care for trans youth. It is also unclear which procedures are directly related to gender-affirming care. Some include descriptions of routine medical claims such as emergency room visits and lipid panels. Only one reimbursement could be more easily connected to gender-affirming care for trans children: $94.20 for "bone age studies."

In a letter to Mississippi Today, Medicaid noted that some claims "may not be directed related to" services for a patient's primary diagnosis of gender dysphoria.

The Division of Medicaid did not answer questions from Mississippi Today for this story.

Earlier this year, Medicaid became the first state agency to take a public position on gender-affirming care for trans children as lawmakers sought to ban it. In mid-February, Executive Director Drew Snyder sent a letter stating that there is not enough medical literature to support that it is a "safe and effective treatment for gender dysphoria" for trans youth.

Snyder's letter did not mention Medicaid reimbursements for gender-affirming care.

Rob Hill, the state director of Human Rights Campaign of Mississippi, said that Snyder's letter contradicts Medicaid's past actions of paying for gender-affirming care. Despite Medicaid's letter, major medical associations support gender-affirming care for trans youth.

"I've always known Drew Snyder to be a fair-minded person, so I would say I was really disappointed to see this letter released that was not based on fact," Hill said. "There is plenty of research that he or his folks in the department could've done. It's easily found on the internet. I could have sent him a fact sheet."

For trans people, it can be challenging to get gender-affirming care covered by private health insurance. Trans people report being uninsured at a rate seven times higher than cis people, due in significant part to job discrimination and the employment-based health insurance model in the U.S., according to a report from the Center for American Progress. That same report found that 46% of trans respondents – and 56% of trans respondents of color – said their health insurance denied coverage for gender-affirming care.

"Honestly, I'm glad to know that people have received (gender-affirming) care in Mississippi through Medicaid, through taxpayer dollars," Hill said. "But I would like to see it be a lot more because this care is well-researched for decades and supported by all the major medical associations."

One of the first signs that gender-affirming care would become a flashpoint during the legislative session came last fall when the Mississippi Freedom Caucus, a far-right wing of the Legislature, published a blog post by Rep. Dana Criswell of Olive Branch that claimed public dollars were funding the "mutilation of children" at the University of Mississippi Medical Center.

"You read that correctly, you, the taxpayers of Mississippi, are paying for children to receive hormone therapy and for mutilation of children," the post read.

But during the legislative session, lawmakers spent little time on the issue of state funds supporting gender-affirming care despite efforts to determine the amount.

Lawmakers' first inquiry to Medicaid came in mid-December from Lonnie Edgar, the deputy director of the Joint Legislative Performance Evaluation and Expenditure Review Committee. The PEER Committee is tasked with assisting legislators with requests for information and the results of its research are confidential.

On Dec. 13, 2022, Edgar sent an email to Cody Smith, an attorney for Mississippi Medicaid, asking if the agency had reimbursed claims for gender-affirming care "anywhere else in the state besides UMMC." Edgar noted that "this is similar to the request you all provided information on about Planned Parenthood facilities on September 13, 2022."

Edgar told Mississippi Today he is not allowed to disclose who made the request or whether any similar requests have been made in the past. He also did not have an answer as to why the request excluded UMMC.

It could be that PEER already had information about the medical center. In August 2022, the PEER committee also sent an inquiry to UMMC asking if it had billed gender-affirming services to Medicaid.

Smith responded to Edgar about two weeks later, writing that Medicaid had determined a total of $131,865.03 was paid for 47 visits. He noted that no payments were made to the Spectrum Clinic in Hattiesburg, the only clinic in the state that exclusively serves transgender patients. Medicaid's research found that the agency has reimbursed providers across the state, including Singing River and UMMC, for care given to people with gender dysphoria.

After House lawmakers passed HB 1125 early in the session, the inquiries from Edgar continued.

"This request seems to change every iteration," Edgar wrote on Jan. 26. "Based on the information you provided on Medicaid claims broken out by provider … can you also determine the amounts spent on puberty blocking hormones or cross sex hormone treatment?"

It doesn't appear that Medicaid was able to determine that amount since Medicaid-enrolled prescribers are not required to give a diagnosis code to pharmacists.

Soon after, Smith and Brett Brown, a technology specialist at Medicaid, discovered an error in the initial accounting.

Brown realized that the previous number Medicaid had provided lawmakers – $131,865.03 – was more than double the actual amount the agency had paid out because it included Medicaid "crossover claims." Crossover claims occur for people who are eligible for both Medicare and Medicaid. Medicare, federal health insurance for people 65 or older, pays a portion of the claim, and Medicaid is billed for any remaining deductible or coinsurance.

Hill said there's "no number" that can be put on the positive impact gender-affirming care has on trans people and especially trans youth.

"Anybody who suggests that it's wasted money – one, I would think that they don't have a heart," he said, "and two, they're just absolutely wrong."

-- Article credit to Molly Minta and Kate Royals of Mississippi Today