Study: Non-discriminatory state-level insurance can improve access to gender-affirming care

Implementation of a state-level insurance policy that prohibits discrimination based on gender identity or gender expression can increase access to gender-affirming surgical care, according to a new study by The Ohio State University Wexner Medical Center and College of Medicine.

The research examined the impact of the California Insurance Gender Nondiscrimination Act, which prohibits insurers from refusing to cover the cost of medically necessary care based on a patient's gender identity or gender expression. The policy applies to all health plans in the state.

The analysis included 25,252 transgender and gender diverse patients in California as well as in Arizona and Washington, which have not implemented similar insurance policies. Researchers found a 12.1% increase in the likelihood of patients having gender-affirming surgery in California than in Arizona or Washington. The findings were published today in the Journal of the American Medical Association (JAMA).

Gender-affirming surgery of the face, chest or genitals is considered medically necessary for transgender and gender diverse patients as well as a cost-effective health intervention, said Dr. Adrian Diaz, a general surgery resident in the Department of Surgery and senior author of the study. At least 1.6 million Americans identify as transgender or gender-diverse, with about 60% expressing interest in gender-affirming surgery, according to the study.

"This research has the potential to have a great impact on the transgender and gender-diverse community because it demonstrates the power that state legislatures have in implementing nondiscriminatory insurance policies and improving access to gender-affirming surgical care," Diaz said.

Studies show that without access to gender-affirming surgical care, patients have higher rates of HIV infection, depression, substance abuse, suicidal ideation and unemployment.

"With the recent national trend of states passing restrictive state-level policies limiting access to gender-affirming care, we felt it was important to understand the effect of already implemented state-level protective, nondiscriminatory policies. This type of research helps inform state legislatures of potential polices that can create a more equitable healthcare environment within their states," said Dr. Anna Schoenbrunner, a plastic surgery resident in the Ohio State Department of Plastic and Reconstructive Surgery and first author of the study.

Researchers noted their findings were similar to what happened after implementation of the Women's Health and Cancer Right Act in 1999, which mandated insurance coverage for breast reconstruction and symmetry procedures following mastectomy. After passage of the act, a study found utilization of breast reconstruction increased by 31% the year of implementation and 36% the following year in states without previous legislation mandating the insurance coverage.