The U.S. House of Representatives passed a budget bill that promises a sweeping dismantling of critical public programs that millions of people rely on, including food stamps, Medicaid, and federal education loans. Buried inside the bill’s thousand-plus pages are provisions that specifically target healthcare for transgender people, including an outright ban on Medicaid coverage for transgender people of all ages.
These provisions are the latest escalation of the immense and overwhelming political attacks on transgender people in America over the last several years, which already include a ban on transgender military members, limitations on participation in sports for children, and openly spreading falsehoods about transgender youth and the healthcare they receive. Instead of focusing on the stigma, violence (which is disproportionately experienced by Black transgender women), and discrimination transgender people face every day that results in severe health disparities, higher rates of poverty, and premature deaths, legislators all over the country are enacting policies that perpetuate these very issues.
Between this congressional budget legislation and the Trump administration’s assaults on transgender youth, military service members, and veterans, concern is growing that this administration’s war on transgender people will soon include efforts to strip transgender Medicare beneficiaries of essential medical coverage. Medicare was created with the intention of ensuring that American adults have access to vital healthcare services as they age and can no longer work, and it has grown to become one of the most well-supported and positively viewed government programs of our time. Weaponizing the Medicare program to impose a political agenda in place of expert medical standards of care would be a deeply concerning development with serious ramifications not just for transgender Medicare beneficiaries but for the practice of medicine in America as a whole.
The issue policymakers should be tackling is not banning medical care for transgender youth or adults but rather ensuring that all people, including Medicare beneficiaries, can access the medical care they need.
According to expert standards of care in transgender health, medical care for transgender people is carefully tailored to align with the recommendations of healthcare providers and each person’s individual needs. To examine the frequency and trends of one particular form of care—gender-affirming surgical procedures—for Medicare beneficiaries, my team and I recently published a study using Medicare claims data. While these surgical procedures are not part of the routine standard of care for transgender youth, they are a medically necessary and important part of care for many transgender adults.
We found that gender-affirming surgeries are exceptionally rare in the Medicare program and that transgender Medicare enrollees in the South are less likely to receive surgery compared to those in the Northeast with similar characteristics (e.g., race, ethnicity, age). These findings stem from discriminatory policies that result in inaccessibility. Medicare beneficiaries face barriers to receiving gender-affirming surgeries because of a lack of access to surgeons, inconsistent and unclear coverage policies, coverage denials, and high out-of-pocket costs. These barriers represent structural forms of stigma that may be particularly elevated for racial and ethnic minoritized populations due to racism. Thus, the issue policymakers should be tackling is not banning medical care for transgender youth or adults but rather ensuring that all people, including Medicare beneficiaries, can access the medical care they need.
Transgender people are under political, social, and legal attack with such intensity that it is easy to lose sight of who—and how many people—are actually directly impacted. To put our study’s findings into context: In 2019, 37.9 million people received their Medicare benefits through Traditional Medicare (our study focused on those with Traditional Medicare and excluded those with private plans, known as Medicare Advantage). Of these nearly 38 million people, we were able to identify about 35,000 transgender adults, which is 0.09% of the Traditional Medicare population. Of this small number of Medicare beneficiaries who are transgender, 1.4% received a gender-affirming surgery in 2019. In other words, less than one one-hundredth of a percent—or 0.001%—of this Medicare population was transgender and received gender-affirming surgery.
Not only is the number of transgender Medicare beneficiaries small and the number who received gender-affirming surgeries much smaller, we also observed a decrease in the number of transgender Medicare beneficiaries who received gender-affirming surgeries over time. This downward trend is unique to the Medicare program, further highlighting access issues for transgender people with Medicare coverage.
To put an even finer point on it: We included a cisgender, or non-transgender, cohort in our study because the same surgeries transgender people need are also often received by cisgender people (e.g., hysterectomies). Overall, each year, about 0.5% of our cisgender cohort underwent procedures that could be considered gender-affirming for transgender people. Our team wanted to see if transgender Medicare beneficiaries face any disadvantages in receiving needed surgical care compared to cisgender beneficiaries. We found that, unlike transgender people, there were no significant differences in the receipt of surgery based on where cisgender people lived. In other words, a cisgender person residing in New York was just as likely to receive a surgery they need as another cisgender person in Texas with similar characteristics. Our findings indicate that transgender adults with Medicare may be uniquely unable to access needed care both because of who they are and where they live.
It is timely and crucial to highlight the facts about gender-affirming care and the Medicare program: Our study suggests that transgender Medicare beneficiaries already face unique access issues when seeking medically necessary care. Just like all Medicare beneficiaries, transgender people are deserving of Medicare coverage. Just like everyone else, transgender people should have the ability to access the care that they need from providers they trust without politically motivated, anti-science barriers imposed by the federal government. Yet transgender people continue to be singled out in political attacks that deny them access to care and services that remain accessible to non-transgender people. This issue has already made its way to the U.S. Supreme Court—which could have dire consequences for the health of transgender people of all ages.
The amount of effort, time, and resources being used to target (and scapegoat) such a marginalized group—and to limit their ability to access medically necessary care, no less—is harmful, imbalanced, and malicious. It is also anti-science. Gender-affirming care is cost-effective, associated with improved mental health outcomes, and considered medically necessary by every major medical organization in the U.S., including the American Medical Association, the American Psychological Association, and the American Psychiatric Association. Polling shows most Americans do not want policymakers to focus on the transgender community. With severe federal budget cuts looming, policymakers should, instead, do something useful and positive: They should act to ensure that all people, including transgender people, can get the healthcare they need.
