Who decides what’s medically necessary?

Mara Keisling

Trans advocate says trans health benefits are about what medical treatments are necessary, not about cost or personal beliefs

TAMMYE NASH  | Senior Editor
nash@dallasvoice.com

Say the phrase “transgender health benefits,” and most people immediately think insurance coverage that pays at least some of the costs of sexual reassignment surgery. But there’s a lot more to it than that.

The problem, said National Center for Transgender Equality Executive Director Mara Keisling, is that issues of medical treatment are being made by accountants rather than by doctors. And trans-phobia is playing a role in too many of those decisions.

Neither the city of Dallas, the city of Fort Worth, Dallas County nor Tarrant County offer fully inclusive health care benefits for their employees. But they are not alone.

According to reports, when city officials in Portland, Ore., voted unanimously earlier this month to offer transgender health care benefits, the city became only the third local government in the nation to do so. San Francisco city and county — one combined government — was first, and Oregon’s Multanomah County was second.

In the business world, the odds are a little better for trans employees looking for adequate insurance coverage. According to the Human Rights Campaign, in 2009, 22 percent of the Fortune 100 companies offered trans-inclusive health benefits, while such benefits were offered by 7 percent of Fortune 500 companies, and 3 percent of Fortune 1,000 companies.

Still, those numbers are dishearteningly low. And sometimes, even when a trans person thinks they are covered, insurance companies — whether in an attempt to cut costs or out of anti-trans bigotry — will find a way to deny claims.

“A lot of insurance plans exclude what they call ‘transition-related care,’” Keisling said. “That can mean a lot of different things, but they all have similar implications.”

“Transition-related care” can be divided into two parts, Keisling said: the costs directly related to gender reassignment surgery, and the other treatments and services that are related, things like checking hormone levels, lab tests, and mental health services associated with the transition process.

“Even someone who has fully transitioned probably still needs to get her hormone levels checked on a regular basis. And insurance companies will deny those claims by saying they are ‘transition-related,’” Keisling said.

This is also the issue of sex-specific care, she continued. After transitioning, a trans woman will qualify for regular mammograms, but not for regular prostate exams — which she still needs, too.

And a lot of trans men face similar difficulties, Keisling said. “A trans man might need a pap smear or some other kind of gynecological care, and they are often told no, insurance won’t cover that,” she said.

She described another case in which a trans man was told by his doctors that he was facing serious gynecological problems and needed to have a hysterectomy. Because he was trans, however, insurance wouldn’t pay.

“Insurance said, ‘No. We don’t pay for sex-change operations. The doctors said this is transition surgery. This is a medically-necessary procedure.’ But they wouldn’t pay,” she said.

But in some cases, the discrimination is even more blatant.

“The insurance for federal government employees specifically excludes coverage for the costs of [gender reassignment surgery], but there have been a number of cases where that was used to exclude coverage of any type for transgenders,” Keisling said.

“I know of a federal employee who was told insurance wouldn’t pay for care for her son’s broken arm because she was transgender. Another trans woman who was anemic and needed transfusions was told insurance wouldn’t cover the treatments because she had ‘transsexual blood,’” she said.

“The list goes on and on. I know another trans woman who was playing for a woman’s softball team and broke her arm during a game,” Keisling continued. “She went to the hospital, had the X-rays and got her arm set. Then the insurance company turned around and denied the claim. They said if she weren’t transsexual, she wouldn’t have been out there playing for a women’s team and she wouldn’t have broken her arm.”

When it comes to these “really egregious stories” that are “so clearly wrong,” Keisling said, the victims can hire lawyers and get remedies through the courts. Still, she said, “You have to know what to do, how to get things fixed.” And court cases aren’t cheap, either.

Still, things do seem to be changing for the better, at least when it comes to federal employees, Keisling said. Federal officials recently issues a letter to employees stressing that when it comes to the exclusionary language in the insurance policy, “surgery means just that — surgery, not pre-operative care or post-operative care. And they stressed that this isn’t a change. They aren’t just now saying that. That has always been the rule. They just want to make sure people know the rule and follow it.”

Officials with the Veterans Administration also sent a similar letter regarding insurance coverage for transgender veterans.

But the message doesn’t seem to be filtering down to lower levels of government. For instance, mayoral runoff candidates in both Dallas and Fort Worth have said that when it comes to the question of health benefits for transgender city employees, they have to study the issue more before deciding where they stand. And for three of them — Mike Rawlings and David Kunkle in Dallas and Betsy Price in Fort Worth — it comes down to a question of costs.

Jim Lane, the other Fort Worth mayoral candidate, said at a recent candidate forum that as it had been explained to him in terms of Vietnam veterans suffering from post-traumatic stress syndrome: In the 1970s, most people dismissed claims of post-traumatic stress. But as medical science has advanced, post-traumatic stress has become acknowledged as a serious problem that requires medical-necessary treatment.

That, Keisling said, is what it all comes down to: What is medically necessary? And who gets to answer that question?

“We want the insurance to cover things that are medically necessary. We are not asking them to cover things that are not medically necessary,” she said. “Boob jobs are not in the medically necessary category. Electrolysis treatments, fertility treatments — those things are not medically necessary.”

Gender transition, though, is different. And, Keisling said, the American Medical Association agrees.

“The American Medical Association has said that transition-related health care is medically necessary. It is not experimental. It is not optional. It is medically necessary,” she said. “And we don’t want insurance companies deciding what is medically necessary. We don’t want city council members deciding what’s medically necessary. We want doctors making those decisions.”

The issue of cost, Keisling said, should not be an issue at all.

In fact, according to HRC’s website on transgender health care, “the annualized costs to the employer of providing insurance coverage for transgender-related care are typically minimal” and even “negligible for medium-sized to larger employers.”

The HRC website notes that the best available data on cost comes from the city of San Francisco and San Francisco County, and only limited data is available even then, since trans benefits are a relatively recent occurrence there.

“The cost of services per employee per year was minimal, with costs per insured per year averaging between $0.77 and $0.96: less than a dollar per year per enrollee,” according to information on the HRC website, which is based on the report San Francisco Transgender Benefit: Actual Cost and Utilization (2001-2006). “The precise number of claimants is uncertain since for most years the data is reported by claim and not by claimant. Thus the average dollars per claimant per year ranged between $3,194 and $12,771. The average five-year cost per claimant was between $15,963 and $63,853 for the period from 2001-2006.”

Keisling said, “Does it cost money to offer these benefits? Sure. But the truth is, it will save more money in the long run. With the proper benefits, people get to be healthy, physically and mentally, and that has an undeniable impact on the quality of the work they do.

“The real problem is that when people think of transition and treatment for transgenders, they think of it as something dirty,” Keisling added. “But it’s not dirty. It’s not shameful. It’s just like any other kind of medical care. This is about medical treatments that are medically necessary and that’s it. That whole debate over ‘medically necessary’ is done. It’s over.

“Now the businesses are starting to fall in line, and even the federal government. Now it’s time for the cities, for the counties to get on the stick and start offering their employees the benefits they deserve.”

—  John Wright