Individuals who purchase health insurance in either the ACA regulated small group or individual markets will be guaranteed that their plans will cover gender affirming care. This is an administrative action that will also allow for individuals who need this care to be able to qualify for zero premium plans.
The Biden administration authorized Colorado to require gender-affirming care coverage as an essential health benefit, a landmark decision for transgender people. https://t.co/Y0lvlqcdkz
— Bloomberg Law (@BLaw) October 12, 2021
Why does it matter that Colorado made gender affirming care an “essential health benefit?”
An Essential Health Benefit (EHB) is a benefit that must be provided. More importantly, for the sake of my lines of research, an EHB benefit is eligible to be paid for with federal premium subsidies. If Colorado mandated gender affirming care for transsexual individuals but did not make it an EHB, needed and neccessary care would lead to a significant increase in net premiums. If Colorado did not mandate gender affirming care, insurers who elected to offer a voluntary benefit would be taking on significant financial risk as only individuals who knew that they needed gender affirming care AND who knew that they were likely to have greater than the incremental premium costs for that care would sign up for the policies that offered that care benefit. It would produce a benefit specific death spiral. Since it is now an EHB, all insurers must offer it and the cost of care is spread through the entire population.
Insurers can still play games with benefit design as gender affirming care is used to treat long lasting, non-acute conditions. Individuals know if they need this type of care well in advance of receiving it. This means gender affirming care can be a means of risk selection and screening. Risk screening by insurers through the means of offering truly hideous benefit packages for gender affirming care or sending people through a paperwork thicket of pre-approvals can lead to some insurers getting a disproprortionate number of people who have potential high cost needs. The next step is for the Center for Medicare and Medicaid Services to begin to risk adjust for gender dysphoria and related diagnosises so that insurers either become actively indifferent instead of hostile to covering individuals who need gender affirming care or aggressively pursue these individuals by offering better benefits.
Elections have consequences.
Hypothetically, if some state banned gender affirming care, would doctors have to refuse surgery on children with ambiguous genitals? A google check indicates that about 1% of births have some ambiguity, though I didn’t find anything on the percentage that eventually have surgery.
@Ken: I don’t know.
States can make it hard to pay for that care but I don’t know.
Aaron Rodgers Mustache
my reservation for four for friday nite at windows on the world says otherwise.
Enhanced Voting Techniques
Speak as someone with a friend who is undergoing Gender Reassignment surgery, what exactly is “gender affirming care”, because my friend sure comes across as needed it. Lonely and confused kind of stuff.
There’s an article in today’s Cincinnati paper about plain old Gay people who can’t find accepting, non-judgemental doctors, and the harms the ensuing avoidance of regular medical care are causing. I admit, something that wasn’t on my radar because I have a cool stable of doctors.
Off-topic, just read elsewhere on the internet that NYT columnist Nick Kistof has left the paper to run for governor of Oregon. Just in case anyone ever doubted the man has always been high on his own supply.
@Ken: A client who is a urologist trained in India says the number of unclear genitalia is 1%. In India there is little surgery performed but there is a long tradition of sending kids with unclear genitalia to live with the hijira. They were considered sacred until the British arrived. They blessed weddings and were venerated. The Brits made them into dangerous predators. Now they frighten shopkeepers into giving them “donations” so they don’t intimidate customers. Colorado is clearing out a nasty remnant of British culture, and of Calvinism.
@Enhanced Voting Techniques: Gender-affirming care is care–including, but not necessarily requiring, surgery–that affirms the gender that someone knows themself to be. In the case of my workplace, this includes behaviors–such as making sure we use the right pronouns with someone–as well as medical care, such as hormones or referrals for surgery. It can include things like utilizing language that makes it more comfortable for someone who has a cervix and identifies as male to still get the preventive care they need (in this case, cervical cancer screening), for example. As Ohio Mom notes, one of the things our providers see all the time is people who avoid medical care because they are on the LGBTQ spectrum somewhere and their previous experiences with the medical industry have been horrible.
@Enhanced Voting Techniques: My experience of trans people in Seattle is different than yours with your lonely and confused friend but there are several great organizations here, some specifically for trans people. The Ingersoll Center for Transgender Rights may have recommendations although I haven’t been in contact for more than a decade. Plus there are lots of trans people here so loneliness is not the same problem as it is in too many areas. There may be free resources available for your friend although abundant counseling would be ideal.
@Dan B: Correction: It’s the Ingersoll Gender Center.
I dont know if they do any remote counseling Zoom or otherwise although they have group discussions which have probably been but they would know of resources outside Seattle.
This is great.
And yet another thing we will have to defend in the ’24 and ’28 elections, since and EO is reversible. The GOP is gonna demagog this like hella. The same people who used gay marriage panic in 2004 to re-elect Duba (yeah, I’m glariin’ at you, fake Democrat Mathew Dowd) are using trans folks now for their hideous electoral crusades.
@RaflW: And every time something like this happens, the people who talk a lot about messaging and framing to reach across the aisle are going to urge us to throw the persecuted group under the bus.
Wow, my state does it again in terms of being a trendsetter. Now if only the Colorado Department of Education would mandate masking and vaccination for public schools, I would be a very happy camper.
There’s also a Chris Hayes “Why is this Happening?” podcast where Hayes interviews Dr. Izzy Lowell about what gender-affirming care is, linked here.
@Ohio Mom: Kristof thinks he can be the next Tom McCall. McCall went from TV news guy to Secretary of State to beloved 2 term Governor.
This is great news, and thanks for the analysis.
@Kelly: I had to google Tom McCall, you are clearly right, that must be Kristof’s inspiration. Also, if non-politicians like Bloomberg, Trump, Yang, Williamson, etc. feel no embarrassment at reaching for what they are clearly not qualified for, why not Nick?
I’ve spent all the time I’m going to on this topic. Somehow I can’t imagine a NYT columnist has as high a profile in Oregon as McCall did, perhaps he’ll rethink this clunker of an idea.
Thank you for this post! When I first saw this headline I was very confused, because in many instances plans have to offer this care already because it is considered discriminatory not to. I did not understand the insurance intricacies at play and now I do. :)
Sister Golden Bear
@Ken: Intersex people are a separate issue, although they definitely face some overlapping issues with trans people.
Surgeon used to routinely “fix” infants with ambiguous genitalia — usually to give them female genitals (as one surgeon put it, it’s easier to create a hole rather than a pole). Normally, the child would never be informed by doctors or parents.
Intersex people have pushed back against this, so best practice (if often ignored practice) is to now wait until the child is old enough to make the decision.
Sister Golden Bear
This is a great step. Up until a few years ago gender-affirming care was almost never covered — in fact my insurer at the time explicitly excluded coverage. Not only for bottom surgery (i.e. “gender confirmation surgery), but pretty much any treatment, although they would cover my hormones.
Bottom surgery is far from the only medical expense involved, I’m approaching 400 hours of facial electrolysis, had breast implants, as well as facial feminization surgery. Not to mention the therapy that’s required to get two letters of approval needed before you can get bottom surgery. All out of pocket.
Trans men may need top surgery (i.e. breast removal) and hysterectomies, and well as potentially phalloplasty. (Fewer trans men opt for this, because it’s expensive and the results are still not as good as bottom surgery for trans women.)
Whether trans people will actually be able to get the care they need paid for will be whole other story.
By the time I had my bottom surgery, CA did require coverage, but the insurance maze made it difficult to actually get it approved. Especially in my case, since I had my surgery done in Thailand (some of the best surgeons in the world for it are there), they wouldn’t cover it, even though they were supposed to. Ironic, in that cost of surgery in Thailand was much less — but obviously denying coverage costs them even less. No, I’m not bitter…
Enhanced Voting Techniques
@Dan B: Ok, the friend is in LA, anyone got suggestions for the LA area?
@Enhanced Voting Techniques: Yes. The LA LGBT Center. It’s an FQHC, so there will be a sliding fee scale, too.
@Sister Golden Bear: WA State passed a law requiring insurance coverage for trans care. It takes effect in January. The same day this passed the legislature two GQP reps proposed bills that would block people from sports and other accommodations unless they fit their gender assigned at birth. They didn’t go anywhere past the speeches these creeps made. Go Lege!
Late to this party, but I remember when my labor union at the University of Michigan pushed to include coverage of gender affirming care in 2005. The university balked at first, then signed a contract that included coverage.
Within a few years, they realized that though the coverage could be expensive on an individual case, that since a very small share of the covered members of the bargaining unit would need coverage, it had nearly zero impact on the bottom line.
And that’s how getting proper health care for trans folks at the university of Michigan became a relatively mundane back-and-forth struggle in line with other sorts of health care problems instead of a supercharged hot-button social issue.