Access to health care for transgender people has improved dramatically over the past several years, in part due to Obamacare’s expansion of Medicaid. Now, the Washington State Health Care Authority, which over sees the program, is weighing rule changes that could tighten access to treatment for trans patients, specifically in cases where Medicaid covers the cost of gender transitional treatments.
Under the proposal, Medicaid would continue to cover the most major gender transitional operations, such as chest and groin surgeries, and many other medical procedures as a treatment for gender dysphoria—the medical condition in which there’s a painful mismatch between one’s lived gender versus one’s body. However, it would no longer cover some associated treatments such as liposuction, trachea shave, or drugs for hair loss or growth, among other things.
Transgender advocates argue the rule changes are arbitrary, and target trans people. A patient and their doctor, they say, should be the final arbiters when it comes to patient health.
The rules “create an unnecessary burden that singles out transgender people, who are the only people as a group who experience gender dysphoria, for differential treatment” from other ailments, Danni Askini, director of Gender Justice League, said at a public hearing in Olympia on Tuesday about the rule change. “This is contrary to law.”
The “list of covered and noncovered services are actually quite arbitrary and capricious,” said Askini. “They are not based on a rigorous scientific methodology that is based on research.” Askini noted that gender dysphoria works differently for different people, and the standards of care for treating the condition are meant to be tailored to a patient’s specific needs, not rigidly forced onto all patients equally.
We previously wrote about one transgender man’s experience navigating the bureaucratic obstacles trans people face when seeking surgery under Medicaid. The new rules, Askini says, would make getting gender dysphoria treatment an even bigger paperwork nightmare than it is now. Along with reducing the number of procedures covered, the new rule would make people jump through more hoops before getting the remaining procedures covered.
The proposed rule changes would “reduce the flexibility that providers are currently entitled to under the rules by making a series of checklists, essentially, that are inflexible,” says Askini. Specifically, the proposed changes would add language saying that patients seeking gender surgery must first complete “all of the presurgical requirements” that are already laid out in the rules in detail. Askini says that this will create less flexibility for doctors to waive those requirements for patients who may not want or need all of them.
HCA spokesperson Amy Blondin was present at Tuesday’s hearing. She says that the proposed changes are not meant to cut off anyone’s access. “The intent of the rules is to provide more clarity and to make sure that the care team decides on the treatment,” she says. There is an appeal process in which patients can pursue if their treatment is rejected by the HCA. “The intent is not to limit any services, but to leave it up to the treatment providers to make those decisions in partnership with the patient.”
Askini agrees with the need to clarify what’s covered, but wants that clarity to broaden access for gender dysphoric patients, not restrict them. As things stand, she says, it’s heard of for doctors to prescribe treatments that are then rejected for payment by the HCA. “It is one reason few providers take Apple Health,” she says, referring to the brand name of Washington’s Medicaid program.
The HCA is listening to the public feedback it’s getting from Askini and others, says Blondin. “Obviously we have a public comment process for a reason,” she says, “which is to hear from people who have concerns…We are absolutely taking all of those into account.”