A reader writes: “As a European living in New York, I find the U.S. health insurance system bewildering, to put it mildly. A German friend just had his bottom surgery done (is in the process of – seems to take a lot of steps, including complications) and there is no question that his health insurance would pay for it.
“In addition, frankly, U.S. medical costs are astronomical. So how does the average U.S. guy pay? At an FTM meeting, I heard a strange comment: ‘I wish I were on Medicaid.’ Is that more likely to pay than health insurance? Seems weird. I checked my own insurance and the alternative available through work, and neither of them pay for ‘gender stuff.’
“At the same time, they have known me as none other than ‘he,’ my documents are in ‘he,’ and even my birth certificate, due to arrive shortly, is in ‘he.’ So if ‘he’ lacks a body part, or the hormones, surely that is no longer gender alignment.”
As an American living in the United States, I find the U.S. health insurance system bewildering as well. In my experience, the bottom line with U.S. healthcare is that most insurance companies will pay for as little as they can get away with, regardless of what medical situation you are in.
However, an increasing number (a very small, very slowly increasing number) are starting to cover some or all aspects of transition. But most do not, and most policies have specific exclusions when it comes to anything related to transition – one thing insurance companies don’t care much about is “gender alignment.”
In a capitalist society, it’s pretty much all about money. Anything that costs money and doesn’t make money is suspect and is examined under a microscope to see how paying for it can be avoided. In addition, and this is my opinion only, I believe that there is an unspoken concept of “morality” underlying many of the decisions that are made about various goods and services that businesses offer to the public.
Although we claim to have a separation of church and state, much of our government policy is based on this vague concept of “morality.” And, of course, private enterprise can do what it wants, but this code of “morality” lingers beneath many of the decisions private companies make, and those decisions are not questioned or protested by the public, because the public is steeped in this concept of what is acceptable – what garners our “approval” – and what is not.
Therefore, while most people would make a stink about a young mother with cancer being denied an expensive, yet successful, treatment by her insurance company (because it would be seen as immoral – just inherently wrong – to deny her this treatment simply because of cost), these same people would not rally to the defense of a trans person needing expensive (yet successful) treatments for transition, because of the question of “morality” – god doesn’t make mistakes, changing your body is wrong, you have a mental illness, not a medical illness, and so on. So insurance companies have little problem getting away with denying these medically necessary procedures.
It is my opinion that a capitalist economic system constructed on top of a series of “moral principles” that cause particular squeamishness when it comes to anything regarding the body results in these (and other) generally accepted insurance policy exclusions.
I think that insurance companies will eventually be forced to add this coverage, but they will not go quietly. Here are a few factors that I think are causing some progress to be made and that have implications for the future:
> The U.S. Tax Court’s decision in O’Donnabhain v. Commissioner of Internal Revenue, which designates transition surgeries and other procedures as legitimate medical expenses.
> The Human Rights Campaign’s (HRC) Corporate Equality Index, which has continued to expand its requirements regarding treatment of trans people in order for a company to receive a high or perfect score. Although HRC has never been a popular organization with the trans community, for a host of legitimate reasons, it is a powerful organization, and many businesses covet a high rating on the CEI. I’m not a fan of HRC, but I’m not going to deny the influence that the CEI has had on corporations offering benefits to trans people, including insurance benefits that cover transition procedures.
> The visibility of trans people in the workplace, which has allowed employers to see that we’re out there and that we are valuable employees that they not only want to retain after transition, but that they actually want to recruit. And the way to both retain good employees and to recruit others is to offer benefits that will attract them.
> The visibility of trans people on Capitol Hill, which has allowed Congress to see us as intelligent, productive, and voting members of society. Although the government has lagged behind big business in recognizing the importance of equal rights and protections for trans people, our presence is absolutely necessary to continue any forward momentum and to avoid slipping backwards. There are varied opinions of the National Center for Transgender Equality within the community, but it is the most powerful and visible trans organization on Capitol Hill.
With regard to Medicaid, my understanding (and I hope readers will correct me if I’m wrong and add what they know) is that it is a jointly funded state and federal program administered by the states, and each state government has the power to decide what Medicaid will pay for in that state.
My understanding is that Medicaid coverage of transition medications and procedures varies from state to state and is often considered on a case-by-case basis. I think that, historically, Medicaid has covered only a handful of transition-related surgeries, so I don’t think Medicaid is the answer – at least not now.
So how do guys pay for their surgery? Many do not. Even today, the majority of guys in the United States do not have genital surgery, although I think the numbers are increasing. One of the primary obstacles is cost. Most guys simply do not have the money and have no way to get it.
A few do work in a setting where insurance covers this surgery. Some have metoidioplasty, with or without testicle construction, which is substantially less expensive than phalloplasty. Some work three jobs to save the money. Some take out a second mortgage (or a third). Some take out loans or borrow from family and go into long-term debt. Some sell their possessions. It just depends on what means (if any) they might have to get the funds.
But again, the reality is that most guys don’t have surgery, and it’s not all a matter of cost. Some guys have health concerns that prevent the surgery, others don’t want to go through the pain, risk, and possible complications, and some just don’t care.
But what the public, the government, and the health insurance companies need to understand is that, for those trans men and women who require genital surgery, or any other type of transition-related surgery, it is a medical necessity and, like any other medical necessity, should be covered by insurance.
Readers – thoughts and information?
Here’s my two cents…
Until the US sees health insurance and what is covered as a right and not a privilege, we will stay right where we are, meaning many will not be able to afford top surgery, never mind any bottom surgery.
As a college student majoring in the helping profession, I am continually surprised by my peers who think that our health care system is just fine. They typically are still covered under their parents insurance, so I wonder if their tune will change when they have to try and pay for it on their own.
Insurance is big (for profit) business that needs to change, but have little motivation to do so.
There is so much wrong with the US and healthcare is but one of the issues that does not affect those who can change things (white elites).
Wow, someone outside our system of medical care actually noticed how messed up it is over here. Yeah!!!! You had such a great ezplaination of the problems, Matt. I have thought it for a long time that it was the underlying morality police (insurance companies) that gave us so much difficulty in receiving needed medical care. Thank you so
much Puritains for setting the moral under pinning that limits our countries ability to be much more open minded concerning equality of every human in this country. I could so easily go off on a huge tirade right now, but I won’t digress.
I have tricare and have actually received a letter from them stating that do not cover any issue involving sexual dysfunction. My therapist filed a claim stating she was treating me for GID prompting the response letter. Last time I checked, GID was not a sexual dysfunction. Tricare on he other hand will cover transition stuff if it is not coded as such. If I can show that I am a male by legal documentation, i.e. Social security records and birth records, then typical transistion surgeries become something else. So a meta becomes a type of circumcision procedure which would be covered. So it becomes a huge catch twenty-two. No surgeries with letters so I can change my legal documents. No legal documents so I can have surgery covered by insurance.
I dont know a lot about the HRC or the NCTE, but something must be happening behind the scences. We did make strides in government this last year. The VA will treat veterns with trans needs upto surgery. You can get preventive procedures covered and receive hormones through them. The Dept of Labor also made statements about hiring practices of transgendered people within there department and it is spreading within other federal departments. I am not sure which method of change is better. Quietly behind the scenes or in the for front of public opinion like marriage equality has put forth. I am guessing in actuality it takes both methods for change to happen.
Capitalism on the level that it has reached is just insane. I believe that there are certian things that just should not be for sale no matter what. Healthcare, housing, and the Presidency are just a few. I feel our government is has throughly been eroded thanks to the huge stream of money flowing to our representatives in government. Again I could take off on a tirade, so I won’t. I wll just say that government and big business forgets where the money comes from and that is us the people. We have the power, not money.
I am just one guy who needs surgery and sees no way to ever make it happen.
“At the same time, they have known me as none other than ‘he,’ my documents are in ‘he,’ and even my birth certificate, due to arrive shortly, is in ‘he.’ So if ‘he’ lacks a body part, or the hormones, surely that is no longer gender alignment.”
I think the asker is wondering if he can get stuff covered as if he were a cisgender man with low testosterone levels and unconventional genitals. I’ve always wondered about that, too. I’d hazard a guess that insurance might cover T if he has a sympathetic doctor who can avoid mentioning his trans status; low hormone levels must be pretty common. Lower surgery would probably be harder: genital reconstruction must be very rare among cis men (except for enlargement, which wouldn’t be covered anyway).
What’s wrong with our healthcare system? Where to begin? Well, it certainly needs an overhaul. For one thing, it’s inconsistent from to state-to-state and from company to company so there is no equality among our citizens when it comes to coverage. In fact, I know people who work in the same city I do, doing the same job at similar firms who pay much more for their meds and copayments. Why is that? What’s wrong with this picture? And I won’t even get into how many people don’t get coverage from their jobs or how senior citizens are getting screwed after working hard and paying into the system all their lives.
I agree that healthcare is big business in this country and the tight-fisted insurance companies have a plethora of excuses to deny coverage because they don’t want to part with cash, so it’s very easy to use the “unnecessary cosmetic procedure” excuse for things like top surgery in order to avoid paying.
I also agree that trans-related meds and procedures are necessary and should be covered, as they are in other countries. However, according to friends from some of the countries with socialized medicine which cover trans procedures (mainly the UK and Canada), their healthcare systems are also far from perfect. Some have to wait ridiculous amounts of time for tests or test results that we can obtain here in much less time (like the friend who had to wait six months for an “emergency’ colonoscopy and another friend who waited over a week for a simple x-ray result before finding out if anything was broken).
And those are the more pressing matters! The stories from those who try to schedule trans procedures are even more frustrating. Right now I’m hearing stories from friends in England who have been having a hard time getting T – apparently there’s a shortage and no end in sight.
So I’m counting my blessings that I don’t have to deal with that. Our system is messed up for sure and it needs help, but sometimes the grass really is greener on the other side.
Yep – it is a very messed up system.
For starters, 99% of insurances have a specific “transgender” exclusion. Then you get into Draconian loopholes such as “pre-existing conditions” and such. I am even reluctant to call up my insurance and ask about any sort of trans coverage for fear of being “flagged” as being transgender and then have coverage for something else denied, or some nonsense like that. And while a diagnosis of GID might help in some cases, I am afraid it might come back to haunt you later on, when they are looking for excuses to deny you coverage.
Even those insurance plans that _do_ cover transition-related costs (which are offered by a few companies in the CEI list, as Matt mentioned above), the requirements are often ridiculous, like being diagnosed with GID for 2 years before any sort of transition costs are covered, and apart from being binary exclusive (must be male/female identified, with documentation), it often includes outdated requirements that are not inline with the new WPATH standards, such as real-life-experience, etc.
All transgender-related issues aside, you will always end up paying a lot more than is fair unless you are super careful.
Yeah guys, get out and vote for Obama so you don’t get one of the wacky Republicans who woould like to deny everyone healthcare who is less than Romney rich!
In California, MediCal (CA version of Medicaid) will pay for transition related surgery. But they put you throuogh the beaurocratic wringer first before relenting – that is if you haven’t given up on it first! The problem is that the DOCTORS who perform top or bottom surgery REFUSE to accept Medicaid or MediCal because these programs pay them so little. Sometimes this is the case for doctors who perform other types of surgeries. Matt, you are correct in who Medicaid works in regards to state and federal funding and that the deal differs depending what state you live in. Also, I like your analysis of the healthcare problem in the US in general as far as profit making and capitalism – so true! Fighting the refusals can be challenging as the paperwork is hard to understand if you’re not a lawyer and the hearings you must attend that you really should have a lawyer go with you to.
I want to predicate my comment by saying – yes, healthcare in the US is broken. That being said, as a healthcare professional (financial) I believe the reasons for non-coverage of gender related services (along with many non-gender related services) are more complex than most people realize.
Yes, there are carriers who deny coverage based on bad science; there are also carriers who justify non-coverage for a variety of other reasons. But this is not a phenomenon based soley on the marginalization of trans people. Carriers don’t like to cover expensive stuff for anyone. For example, you would be appalled at how many carriers don’t cover petscans (a really important radiological exam) for patients with pancreatic cancer. Why? Because it generally won’t increase their life expectancy (read between the lines – its very fatal, so they’re not going to shell out that kind of money for a patient who statistically speaking isn’t likely to survive anyhow). Again, I am NOT saying I agree, but I am saying it isn’t just Trans people who are being denied important medical care.
So what’s the solution? That’s the trillion dollar question right there. Government control of our healthcare system literally makes my stomach turn. Because if you think private insurers are bad you should see the crap that Medicare and Medicaid pulls. Additionally, the reimbursement provided by these agencies isn’t sustainable in the long run; at least not if we would like to retain our current level of medical expertise and innovation (not to mention access).
I could go on and on, but I’ll spare you. My suggestion for those of us with no coverage for our transition – educate your companies. My company has coverage through WellPoint who does cover gender reassignment; but because we are self-funded (ie we pay our own claims) the company is able to exclude coverage for us (despite the fact that I work for an ivy league medical research center which HAS a transgender clinic…ugh.) so, I have an appointment to meet with our medical policy board. I’ll discuss GID and why treatment is so important. I will try to educate them. And I encourage you all to do the same – talk to your employers, talk to your carriers, talk to your legislators. If we don’t make the effort to fix the problem, we have no business complaining about it. Just my two cents.
Health care in the United States– where to begin? I echo much of what has already been said, and, yes– no question, my vote is for Obama.
For any guys seeking basic reproductive care (and, in some states, counseling and hormones), Planned Parenthood can be a great resource. Their sliding fee scales help make care and procedures affordable, and they are very often LGB -and- T supportive. They are referral experts, also, and can provide you with a list of supportive medical professionals (often with sliding fees themselves) who provide the care you need, in case PP doesn’t offer it. If it were not for them, I would not get the scary annual visit, but they make it possible (and painless).
And, for anyone college-bound, The Advocate Guide for LGBT Students (http://www.amazon.com/Advocate-College-Guide-LGBT-Students/dp/155583857X) gives a somewhat-dated but very useful list of colleges who provide (and some who even pay for) trans care for their students.
This is one of the few things for which I am grateful to be in my country; though I’ll never let one of those butchers do lower surgery to me *shudders*, I won’t have to pay for hysterectomy and top surgery.
And this is only about the trans-related stuff; I’d never be able to afford any treatment I’ve received so far if we didn’t have public health care.
Sure health care maybe isn’t perfect here, but US health “care” system is one of the reasons, no, probably THE main reason why I’m glad I’m not from the US