The board on Dec. 7 voted 7-3 against the proposal, which would add coverage to the city's self-insured medical plans for medical procedures deemed necessary to treat people diagnosed with gender dysphoria.
This includes mental health care, hormone therapy, hair removal, gender affirmation surgery and other forms of gender-affirming care, according to a report from the Metro Human Relations Commission in support of adding the health coverage.
Metro Council member and LGBTQ Caucus Chair Nancy VanReece said efforts to add this type of coverage have been ongoing for about five years. She said she was "disappointed" and "bewildered" by the board's discussion and vote on Dec. 7.
Mayor John Cooper's administration also conveyed its "strong support" for the proposal before the vote and expressed disappointment with the outcome in a letter to the Metro LGBTQ Caucus on Dec. 14.
Cooper cannot reverse the decision or mandate the coverage by executive order, nor can Metro Council perform those actions through ordinance, according to the Metro Legal Department.
In the note, Metro Director of Legislative Affairs Mike Jameson and LGBTQ Liaison for Cooper's office Brandon Marshall said city officials plan to bring the proposal back to the board for reconsideration in June.
"We cannot dictate or ensure members' future votes," the letter states. "Indeed, we assure nominees to boards and commissions that they should exercise their best independent judgement — though we do convey administration policy positions on significant matters." VanReece and Marshall, on behalf of Cooper's administration, testified in support of the proposal at two board meetings before the vote.
"I don't see anybody giving up on it, and we'll continue to do everything we can to see that this is added to the benefits package," VanReece said.
Hal Cato, the longtime CEO of nonprofit Thistle Farms who recently announced his resignation and possible interest in running for mayor, tweeted after the vote: "When good people stand by and do nothing, their communities will be consumed."
Board members' brief discussion included concerns of discrimination, cost
Metro Employee Benefits Board member B.R. Hall, who voted against the proposal, said he viewed the addition of transgender-inclusive benefits as "a discriminatory practice."
"Not only are we carving it out and giving it to one group and not giving it to another group, we're asking the other group to help pay for it," Hall said. "If we want to offer a cosmetic surgery to everybody, I'm willing to consider that. I'm not saying I'm willing to vote for it."
Board member Christine Bradley, who also voted against the proposal, said Metro is also "behind the curve" on offering coverage for plastic surgery following extreme weight reduction.
"I think this does open up a bit of a can of worms," Bradley said.
A memo from the Metro Department of Law distributed to board members before the Dec. 7 meeting stated that adding coverage for gender-affirming medical care would not legally constitute discrimination against people with body dysmorphia who are denied coverage of cosmetic procedures.
Adding transgender-inclusive care to Nashville's employee health insurance benefits "should not impact the health insurance premiums that are paid by any Metro Government employees," according to the Metro Human Relations Commission report, also distributed to board members before the vote.
The Williams Institute, a UCLA School of Law research center, surveyed 34 employers who provide transition-related health coverage in a 2013 study, finding 85% reported the addition of gender-affirming coverage resulted in no additional cost.
A very small percentage of employees seek transition-related medical care, according to the Metro Human Relations Commission report and multiple research papers, meaning costs end up being "nominal or nonexistent."
Board member Jeremy Moseley voted in favor of adding the coverage, saying it is not required under state or federal law but cost-effective in the long run through savings in alcohol and drug treatment, mental health treatment and attempted suicide for some people who want to transition but cannot without coverage.
"I think for a few pennies on the dollar that we're potentially talking about from an insurance standpoint, if we're looking at what the potential cost savings would be, then we're not shelling out," Moseley said. "I don't think this is going to be something that's going to be drastically used across the board, realistically."
The American Medical Association, the American Psychological Association, the National Association of Social Workers and the World Professional Association for Transgender Health deem gender-affirming procedures medically necessary.
Nineteen states and Washington, D.C., have outlawed insurance exclusions for transgender health care and include protections in state Medicaid for transgender health care, according to the Human Rights Campaign.
Austin, Texas — a city often used as a comparison gauge for Nashville's growth and development — is one of several cities to provide transgender-inclusive health care options, and has offered these benefits in all of its health insurance plans for employees, retirees and employee dependents since 2016.
"I remain optimistic and do not expect the city that I know and love to do anything other than the right thing when given the opportunity, and I was disappointed in this vote, but it will come back again before this fiscal year is up," VanReece said.
Reach reporter Cassandra Stephenson at [email protected]. Follow Cassandra on Twitter at @CStephenson731.