The AAPS 102nd Annual Meeting

Effect of Legislation Mandating Insurance Coverage on Access to Surgical Care for Minority Transgender Patients

Kirsten Schuster MD JD, Stephen Stearns BS, Angelica Hernandez Alvarez MD, Iulianna Taritsa BA, Jose Foppiani MD, Daniela Lee BS, Samuel Lin MD, MB

Beth Israel Deaconess Medical Center, Division of Plastic and Reconstructive Surgery, Harvard Medical School, Boston, MA

Background

•An estimated 13 percent of transgender patients in the United States identify as Black yet these patients account for only 2.6 to 9.7 percent of all patients undergoing gender affirming surgery (GAS). [1-3]

•In addition to other barriers, insurance coverage for GAS has been a significant challenge with a significantly higher proportion of transgender patients of color (TOPC) being covered by Medicaid or being uninsured. [1,4]

•Insurance coverage in the 25 states with early adoption of the Affordable Care Act’s (ACA) Medicaid expansion provision first became effective January 1, 2014. Since then, an additional 15 states have expanded coverage. [5]

•29 states have explicit regulatory provisions or judicial rulings mandating Medicaid coverage of gender-affirming care for adults. [6,7]

Purpose

•Previous studies have shown in general that legislations mandating insurance coverage of GAS have been associated with an increased number of patients receiving care. [8]

•This study sought to specifically examine racial differences in patients undergoing GAS and the disparate effects of these legislations on TOPC.

Methods

Search Strategy

•National Inpatient Sample database from 2013 to 2019 searched using ICD diagnosis and procedure codes to identify patients diagnosed with transsexualism or gender identity disorder who underwent genital- and/or breast-related GAS

•Patients without reported race were excluded.

STATISTICAL ANALYSIS

•Patients were stratified by race (white versus non-white) and payer type

•Primary payer was converted to a percentage of total GAS performed by race to account for racial distribution of patients. Percentages were averaged across pre-policy (2013-2014) and post-policy years (2015-2019) for both cohorts.

•Data was analyzed using Z-test and Fischer’s Exact Test

Results

Discussion

•Post-legislation, there was a significant decrease in the percentage of patients using self-pay among Whites and Non-Whites and an increase in proportional utilization of Medicaid among TPOC.

•Expansion of publicly funded insurance, in terms of coverage and eligibility, is associated with improved access to GAS, especially for TPOC.

•Although this disparate effect likely holds no legal power to compel broadened eligibility requirements or coverage of GAS under insurance policies, it emphasizes the importance of continued lobbying for Medicaid expansion on both fronts.

Limitations

•Unable to examine by geographic area in order to more firmly establish a causative effect secondary to overall lower numbers of TOPC undergoing GAS each year.

•Does not account for other barriers to care including lack of trained healthcare resources and lack of resources for recovery including social support, permanent housing, and job security.

References

1. Herman JL, Flores AR, O’Neill KK. How Many Adults and Youth Identify as Transgender in the United States? Los Angeles, CA: University of California Los Angeles School of Law, Williams Institute; 2022. Available at: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf. Accessed March 24, 2024.

2. Tran BNN, Epstein S, Singhal D, et al. Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases. Ann Plast Surg. 2018;80(4):S229-S235. doi:10.1097/SAP.0000000000001350

3. Canner JK, Harfouch O, Kodadek LM, et al. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg. 2018;153(7):609-616. doi:10.1001/jamasurg.2017.6231.

4. Medicaid and CHIP Payment and Access Commission. Access in Brief: Experiences of Lesbian, Gay, Bisexual, and Transgender Medicaid Beneficiaries with Accessing Medical and Behavioral Health. June 2022. available at: https://www.macpac.gov/publication/access-in-brief-experiences-of-lesbian-gay-bisexual-and-transgender-medicaid-beneficiaries-with-accessing-medical-care-and-behavioral-health-care. Accessed March 24, 2024.

5. Drake P, Tolbert J, Rudowitz R, Damico A. How Many Uninsured Are in the Coverage Gap and How Many Could Be Eligible if All States Adopted the Medicaid Expansion? San Francisco, CA: Kaiser Family Foundation; 2024. Available at: https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion. Accessed March 24, 2024.

6. Chin MG, LaGuardia JS, Morgan KBJ, et al. United States Health Policies on Gender-Affirming Care in 2022.Plast Reconstr Surg. 2024;153(2):462e-473e. doi:10.1097/PRS.0000000000010594.

7. Utah Dep’t of Health and Human Servs. Utah Medicaid Provider Manual, Section 2: Physician Services Manual. Available at: https://medicaid.utah.gov/utah-medicaid-official-publications. Accessed March 24, 2024.

8. Faletsky A, Jonczyk MM, Guo L. Legislations Mandating Insurance Coverage Are Highly Effective in Delivering Surgical Care of Transgender Patients. PRS Global Open. 2022;10:e4496.

The AAPS 102nd Annual Meeting

Effect Of Legislation Mandating Insurance Coverage On Access To Surgical Care For Minority Transgender Patients

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