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How to expand health care coverage for trans and gender diverse populations

Public and private insurers should increase reimbursement for diagnoses associated with marginalized populations.

Globe staff illustration; netrun78/Dmitry Ersler/Adobe

This week was Transgender Awareness Week. While awareness is important, our communities need action — health care in Massachusetts and across the nation sorely needs to become more inclusive. Surveys show that transgender and gender-diverse (trans) populations are both a growing demographic and chronically underserved. But despite this fact and the numerous political attacks targeting trans youth, there is hope on the horizon.

One bright light is the practical steps that the Massachusetts Division of Insurance is taking to improve health care. The agency recently held listening sessions to reaffirm its commitment to the medical necessity of gender-affirming care. But defending the need alone will not advance health equity. To make real progress, officials need to incentivize care to our most vulnerable.


To start, this means incentivizing access and the expansion of compassionate and competent gender-affirming health care providers. Many such approaches have been taken, including revamping curriculums, expanding educational access, and augmenting e-consultation services.

Commercial health care rates are based on little solid information and are often negotiated without input from broader audiences. In our communities, health care is often a place of neglect, abuse, and rejection. By the time patients end up at our health care center, their mental and physical health needs are often acute and require significant time and attention to mend. The rates of reimbursement we receive cover a fraction of what is required to care for a patient. Rates for reimbursement must be increased to accurately account for the work we are doing. Otherwise, the care won’t happen, or will forever be linked to charitable giving, which is inefficient and inequitable at best.

One approach that has not been explored is for public and private insurers to increase reimbursement for diagnoses associated with marginalized populations — such as gender dysphoria. To address a multifaceted new market with intention, providers need higher-level payments.


LGBTQI+ individuals often face several hurdles that make health care inaccessible. Recent reports have revealed that over half of trans individuals face discrimination and postpone or avoid health care services. These numbers increase for trans people of color. These rates of discrimination greatly impact a person’s ability to be hired or retain employment, especially for LGBTQI+ adults with disabilities.

Increasing reimbursement would serve as the carrot for more providers to offer gender-affirming health care. And there is precedent: MassHealth recently increased rates for facial surgeries associated with a gender dysphoria diagnosis.

Additionally, MassHealth has continued to outline a pathway to address structural racism and reduce health disparities overall. This is outlined in MassHealth’s request to extend the 1115(a) demonstration waiver, which will improve quality of care and establish greater control over spending. The request also continues to seek authority to increase incentives for lifesaving care. A similar approach can be taken for the trans community. Payers can increase reimbursement for those diagnosed with gender dysphoria. While this diagnosis can be unnecessarily stigmatizing at times, it also allows trans people to access lifesaving health care.

Increased reimbursement for treating trans individuals aligns with MassHealth’s proposal to advance overall health equity. MassHealth leads the way in gender-affirming care and can continue to push the insurance marketplace forward on a more equitable path for trans communities.


Increased reimbursement for gender-affirming care will not only improve access but will also have the added effect of collecting more sexual orientation and gender identity data and will reduce discrimination by incentivizing reasons to promote patient safety and trust in a health care setting, largely by investing in gender-affirming clinical competency. When more health care centers, clinics, and hospitals are incentivized to treat trans individuals, more clinicians will ask about names, pronouns, and gender identity, allowing for more data on the needs of trans people. This data is the first step in knowing what problems face local trans communities and then designing and implementing programmatic and policy interventions to address existing disparities and provide person-centered care. We do not count if we are not counted.

The more clinicians and organizations are aware of and attending to the needs of their trans patients, the more avenues will open for education and systematic programs to attend to those needs. More clinicians caring for the needs of trans people could allow for more compassionate people providing affirming care and speaking out about harmful care when they see it. It is a cycle we need to kick-start.

Some may say that increased reimbursement would only increase the number of clinicians who have no experience or training in gender-affirming care doing this work. But this is how progress works. In tandem with increases in reimbursement, payers should work with experts to expand clinical competency and offer training to increase quality of care. This must be a comprehensive effort.


Overall, increasing reimbursement for those who treat individuals at the margins is the next step in achieving health equity. Our health infrastructure should be measured by how we reach those pushed to the margins. Massachusetts should take the next step and invest in caring for those who need it most.

Dallas Ducar is the founding CEO of Transhealth Northampton.