PA To Start Enforcing Obamacare Rule Regarding Gender Transition Coverage

Sep 13, 2016

Landon DePaulo’s manniversary is Dec. 27, 2012.

That’s when he injected his first $100 shot of testosterone. It's a steep cost to look like himself, he said.

“I work hard and I work long hours, but at the end of the day I still can’t even swing that,” he said. “It’s really discouraging, it’s put an obstacle and a barrier in being who I am.”

DePaulo, 31, wouldn’t stand out in a crowd. At 5-feet-5, he's muscular with thick, dark brown hair and a close-cut beard. He’s a little bit of a hipster and a little bit of a jock. DePaulo said he works out regularly and plays volleyball, always with his shirt on, because of the binder he wears to hide his breasts.

"You’re basically binding your chest,” he said. “And what it can do is it can lead to bruising of the ribs, breaking ribs. It’s just very painful.”

DePaulo wants to make the look permanent through surgery, but he said there’s no way he could pay for the roughly $9,000 double mastectomy on his own. So he’s raising money through events like a keg party and Go Fund Me page. He has insurance, but like most policies, it doesn’t cover top surgery for transgender men.

That could be changing though, thanks to the U.S. Department of Health & Human Services’ interpretation of a clause in the Affordable Care Act about gender discrimination. Earlier this year, the department clarified the 4-year-old rule, saying it applies to gender identity as well, said Harper Jean Tobin, policy director for the National Center on Transgender Equality.

“What the federal law says is, yes, you can’t have an exclusion for transition-related services. What it also says is you have to provide services for gender-transition at least to the same extent that you provide similar services for people with other medical conditions,” she said. “Most, if not all of the services that might be medically necessary for gender transition are already provided.”

For example, if an insurance company would cover a medically necessary hysterectomy for non-transgendered woman, the company also has to cover a hysterectomy for a trans man, if it’s medically necessary.

But the idea of medical necessity is tricky, according to Elizabeth Miller, head of UPMC’s Division of Adolescent and Young Adult Medicine and one of the driving forces behind the creation of the Gender and Sexual Development program. Miller said, in the context of gender transition, the idea of medical necessity has a lot to do with the phenomenon of gender dysphoria.

“In the sense that, offering to a 12-year-old who identifies as male, but has just started menarche, which is the onset of menstruation, being able to block that and the progression, development of a female body that doesn’t match their gender identity feels medically necessary,” she said.

Doctors who treat patients with gender dysphoria often consider gender transition services to be medically necessary to achieving or maintaining mental health. Miller said the consequences of not treating the condition can be dire.

“The very, very high rates of suicide, the high rates of depression, anxiety, post-traumatic stress that accompany the daily pain of not being able to live one’s gender identity,” she said.

Miller said insurance companies have sometimes kicked back claims for services related to gender dysphoria or gender transition, deeming them not medically necessary. But she said that’s happening less and less, ever since the federal government clarified the gender non-discrimination rule in the ACA and states have begun to enforce it. The Pennsylvania Insurance Department put out a notice this spring spelling out what insurance companies can and can’t do.

“From the insurance department’s perspective and I know for Governor Wolf, it’s really important to us to ensure that Pennsylvania is welcoming and provides an inclusive environment regardless of race, color, religion, sexual orientation, gender, gender identity or expression,” said Insurance Commissioner Teresa Miller.

She said they are currently reviewing policies to make sure they comply with the rule.

As happy as DePaulo is with the new rules regarding gender transition coverage, he said it’s just one of many changes needed when it comes to equity in health care.

“(Health care) is not a privilege. It doesn’t matter what your situation is, it shouldn’t have to matter,” he said. “We’re all humans and we all deserve to be well and we’re not doing a very good job of that right now. I’m trying to get there myself, once I get there my goal is to help other people out.”

DePaulo has raised almost half of the money he needs for his surgery, which he is hoping to get done by the end of the year. He said he looks forward to playing volleyball with his shirt off next summer.

Health care coverage on 90.5 WESA is made possible in part by a grant from the Jewish Healthcare Foundation.