We celebrate LGBTQ pride this month. In California a point of pride is the state’s long-standing coverage of gender-affirming care for transgender and non-binary Medi-Cal beneficiaries. The road to coverage has had several bumps, and there are still instances where people are not able to get the treatments they need. While we celebrate California as a trailblazer in covering a broad range of gender-affirming treatments in Medi-Cal, we also recognize that the state still has more work to do to ensure transgender and non-binary Medi-Cal beneficiaries have access to the full range of services they need.
What is gender-affirming care?
Transgender and non-binary people may be diagnosed with gender dysphoria, a condition that manifests as significant distress when people experience conflict between their assigned gender and the gender with which they identify. Some transgender and non-binary people experience a conflict between their assigned gender and gender identity without distress. But when people do experience clinically significant distress, they may require treatment to alleviate the distress. The standards of care for treating gender dysphoria involve a range of options depending on the needs and desires of the person seeking treatment. Together, these interventions are known as gender-affirming care. Gender-affirming health care interventions may include hormone therapy, surgical interventions, speech and language interventions, and behavioral health services. Not all transgender or non-binary people seek all health care interventions, and some may seek none. When people seek these interventions to treat gender dysphoria, they are considered medically necessary when treatment is consistent with the standard of care.
A short history of Medi-Cal coverage of gender-affirming care
In 1974, California’s Medi-Cal agency promulgated a bulletin that prohibited Medi-Cal payment for interventions related to surgical treatments for gender dysphoria. The case was challenged by two transgender individuals – G.B., and J.D. – whose cases reached the California Court of Appeal in 1978. The Court ruled that G.B. and J.D. were entitled to have the gender-affirming surgical treatments they sought covered by Medi-Cal, since they were medically necessary to treat the individuals’ Gender Dysphoria, and were not cosmetic for that purpose. In the years that followed, however, Medi-Cal continued to exclude coverage of many gender-affirming treatments. Finally, in 2001, a California judge ordered the Medi-Cal agency to rescind its policy that automatically denied coverage for gender-affirming surgical procedures, and to instead review all requests on a case-by-case basis. Doe v. Bonta, Sacramento Superior Court of the State of California (case no. 00CS00954, January 29, 2001).
Even after the court’s decision in Bonta, many transgender and non-binary Medi-Cal beneficiaries found accessing the gender-affirming services they needed difficult. In 2013, after years of advocacy by LGBTQ and health equity advocates, including the Health Consumer Alliance, of which National Health Law Program is part, California’s Medi-Cal agency released guidance to providers and managed care plans, clarifying the scope of Medi-Cal’s coverage of treatments for gender dysphoria. The guidance was updated and further clarified in 2016 to include a discussion of the ACA’s non-discrimination provision (Sec. 1557), which was defined in regulations to prohibit categorical exclusions of gender-affirming treatments. Today, transgender and non-binary Medi-Cal beneficiaries can access myriad medical interventions to treat gender dysphoria, including behavioral health services, hormone therapy, and a variety of surgical procedures.
Looking ahead: Ensuring California continues to provide full access to treatment for transgender people in Medi-Cal
California has come a long way to make sure that transgender and non-binary Medi-Cal beneficiaries have full-access to the medical services they need. That is particularly important today, when LGBTQ rights, and in particular the right of transgender and non-binary people to access health care, are under attack by federal agencies, in the federal courts, and by other states. But there is still more work to be done in California. First, there are not enough health care providers in the state to meet the demand for certain interventions including some gender-affirming surgeries. Second, managed care plans sometimes deny medically necessary treatments for gender dysphoria as cosmetic. Third, transgender and non-binary people still face high incidence of discrimination and refusals in health care settings in the state. So as we celebrate Pride this year in California, and we commend the state for taking important steps forward to ensure that transgender and non-binary people in the state have access to the health care services they need, we must continue the work to end discrimination and remove enduring barriers that prevent access to care.