The coronavirus pandemic has made it clear that Americans need better health care access, especially for those who are most marginalized. States should reassess what is considered medically necessary to expand equitable coverage and access — including for transgender and gender-diverse people.
On Sept. 3, MassHealth took that next step forward. It updated the state’s Guidelines for Medical Necessity Determination for gender-affirming care. MassHealth uses these guidelines to determine what care is deemed necessary and paid for. Gender-affirming services currently include services such as hair removal, surgery, pubertal blockade, and hormone therapies. Expanding access to these services will improve mental health and save lives.
This expansion of access has been sorely needed. Unfortunately, coverage for gender-affirming services has been trailing behind the needs of the trans and gender-diverse communities. These guidelines are the next step in a long fight for comprehensive health care, and we should applaud them.
Coverage in Massachusetts has continued to advance over the years:
▪ In 2014, the Commonwealth issued a bulletin prohibiting discrimination in insurance based on gender identity or gender dysphoria.
▪ Also in 2014, the Patrick administration enacted reforms to ensure surgery and hormones were covered under MassHealth.
▪ By 2019, MassHealth once again revised guidelines to expand coverage of gender-affirming care. This included expanded access to gender-affirming surgeries, speech therapy, some facial surgeries, and clarified clinical documentation that would be required.
▪ More recently, in 2021, the attorney general’s office reminded providers that MassHealth gender-affirming surgeries are covered.
There have also been advances on the national level:
▪ In 2010, the Affordable Care Act was passed into law, including Section 1557, which prohibited discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs or activities.
▪ Since the Supreme Court’s 2020 Bostock decision, which prohibits employers from discriminating on the basis of an employee’s sexual orientation or gender identity, the federal government and advocates have pushed for Section 1557(a) to cover gender as it does sex assigned at birth.
▪ Additionally, the recent executive order on equity directed the federal government to ensure adequate nondiscriminatory coverage for gender-affirming care in federal employee health plans.
These advances are landmark examples of how the government has led by example in advancing care for trans and gender-diverse individuals. The new MassHealth guidelines will cover more services and remove some onerous requirements that have kept trans and gender-diverse communities from receiving services.
Private payers, on the other hand, have traditionally relied on the World Professional Association for Transgender Health Standards of Care 7 to determine necessity. More recent statements by WPATH have affirmed that every trans and gender-diverse person has specific desires regarding timing, types of gender-affirming care, and types of social transition needed. There’s no one size fits all model.
Private insurers have attempted to apply a more restrictive model by following WPATH standards, although they have not been updated in a decade. Since then, clinicians and scientists have published more robust and expansive literature, yet insurers continue to adhere to older literature. While there will be an update to the WPATH standards soon, insurers do not need to wait for them.
MassHealth has made a move in the right direction by recognizing the variability in gender-affirming care. It’s time for private payers to follow this same path. To be sure, there are concerns that individuals will join MassHealth or other insurers strictly for gender-affirming care and then leave. These arguments are scarecrow arguments and advance the idea that gender-affirming care is a lifestyle choice. The fact is, gender-affirming care is life-saving care.
Massachusetts prides itself on its health care infrastructure, yet this is an example of the government leading through innovation. We need private companies to also lead the way in innovation and not rely on the government to always set the example.
Gender-affirming care is only the first step. When we care for our most marginalized, we provide better health care overall. We all have some relationship to gender. We know that caring for the whole person allows for better health and decreases the overall costs.
Gender-affirming care offers a model for all of health care. This move represents the impact of an informed, engaged, and active patient population advocating for life-saving care and the government responding appropriately. This moral arc moves toward integrated and comprehensive care to address what it means to be human. This is the next step in creating a genuinely patient-centered health care system.
Dallas Ducar is a nurse practitioner and the founding CEO of Transhealth Northampton.