The pandemic forced my transgender wife to fight our hormone insurer

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GUNNISON, Colorado – For the past eight years my wife, Ky Hamilton, has been on gender-affirming hormone therapy. As a transgender woman, she injects Depo-Estradiol liquid estrogen into her thigh once a week. This drug allowed her to make the physical transition as a woman, and each vial, which lasts about five weeks, was fully covered by insurance.

That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in the Colorado Affordable Care Act market. We found out that our new Anthem insurance does not cover Depo-Estradiol and would cost $ 125 out of pocket per vial. With the two of us – and our four pets – heavily reliant on Ky’s $ 649 weekly unemployment check, such medical expenses have proven difficult. And to September 6, those unemployment checks have run out.

“I am absolutely stressed. I don’t know what to do, ”Ky said in August as we tried to find a solution.

Due to Ky’s physical transition as a transgender woman, her body no longer produces the testosterone it once was. Thus, without the drug, she would essentially go through menopause. Lower estrogen levels can also cause transgender women to lose the physical transitions they have made, leading to gender dysphoria, which is psychological distress due to the mismatch between their biological sex and gender identity.

Ky Hamilton carefully loads her dose of liquid estrogen into a syringe. For eight years, she took gender-affirming hormone therapy, which was fully covered by insurance until she lost her job in April 2020. Like other transgender people, she had to fight for coverage. of its new Affordable Care Act insurance plan. (Hélène Santoro for KHN)

Sadly, Ky’s experience is shared by many other transgender Americans. The covid-19 pandemic has caused millions of people to lose their jobs and private health insurance, especially LGBTQ adults, who have reported higher rates than non-LGBTQ adults that they lost their jobs during the crisis. As a result, enrollments increased in ACA and Medicaid plans, the federal health program for low-income people. Yet many of these plans do not fully cover gender-affirming care, in part because of conservative policies and the lack of scientific research on the importance of such care for transgender patients.

According to a survey by Out2Enroll, a national initiative to connect LGBTQ people to ACA coverage, 46% of 1,386 money market plans surveyed cover some or all medically necessary treatment for gender dysphoria. However, 7% have trans specific exclusions, 14% have exclusions and 33% do not specify.

“It’s this incredible situation where the plans for the most part don’t have blanket exclusions, but where people still have a hard time getting specific procedures, medications, etc.,” said Kellan Baker, Executive Director of the Whitman-Walker Institute, a non-profit organization that focuses on LGBTQ research, policy and education.

Twenty-three states and Washington, DC, include gender care in their Medicaid plans. Corn 10 states exclude such coverage entirely. In 2019, an estimate 152,000 transgender adults have been enrolled in Medicaid, a number that likely increased during the pandemic.

Yet even in states like California that require their Medicaid programs to cover gender-affirming care, patients still struggle to obtain injectable estrogen, said Dr. Amy weimer, an internist who founded the UCLA Gender Health Program. While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must seek treatment authorizations to prove that their patients need the drug. Weiner said these are rarely approved.

Such “pre-clearances” are an issue in the Medicaid and ACA plans for drugs, including injectable estrogen and testosterone, which are used by transgender men, Baker said.

The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed by transgender women to make a physical transition, is not commonly used by non-trans women who are on hormone therapy to treat. menopause or other problems, Weimer mentioned.

A vial of Depo-Estradiol, along with the alcohol swab and syringe Ky Hamilton uses to inject himself, sit on the bathroom counter. Depo-Estradiol is a liquid estrogen commonly used by transgender women, but many Affordable Care Act and Medicaid health plans do not cover it. (Hélène Santoro for KHN)

This may also be because cheaper options, including daily estrogen pills, exist, but they increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said. As a result, many Weimer patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get each month.

While such insurance gaps existed long before the pandemic, the current crisis appears to have magnified the problem, according to Weimer.

The ACA prohibits discrimination based on race, color, national origin, age, disability, and gender in health programs and activities that receive federal funding. The Trump administration has significantly reduced the power of this provision, including eliminating health insurance coverage for transgender people.

Ky Hamilton injects estrogen into her thigh every week to maintain the correct level of the hormone in her system. Because her body no longer produces testosterone, as a transgender woman, she would essentially go through menopause without this drug. (Hélène Santoro for KHN)

However, in June 2020, before the Trump regulations could go into effect, the Supreme Court ruled in Bostock v. Clayton County, Georgia, that discrimination in employment on the basis of sex includes sexual orientation and gender identity.

This landmark decision served as a crucial tool in addressing LGBTQ discrimination in many aspects of life, including healthcare. Since July, for example, Alaska Medicaid can no longer rule out gender-affirming treatment after Swan Being, a transgender woman, won a class action suit that relied in part on the Bostock decision.

The Biden administration announced in May that the US Bureau of Health and Human Services for Civil Rights include gender identity and sexual orientation in its application of the ACA anti-discrimination provision. The following month, Veterans Affairs health benefits were expanded to include gender confirmation surgery.

But for now, the pressure is still on patients like Ky to stand up for their health benefits.

Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of drugs covered by its ACA plans, although many of its private, employer-sponsored plans do cover it.

Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls – and just before unemployment ended – Anthem has finally cleared its Depo-Estradiol. This brings its cost to $ 60 per vial for next year. It’s still expensive for us right now, but we’ll find a way to make it work.

“The reality is that trans people are more likely to be in poverty and don’t have the time or the knowledge to spend four months fighting to get their estradiol like I did,” Ky said. .

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