Association of Health Policy With Payment, Regional Shifts in Gender-Affirming Surgery

 Sacha C. Hauc, MPH¹; Aaron S. Long, BS¹; Mohammad Ali Mozaffari, MD¹; et al

doi:10.1001/jamasurg.2022.1053

Important insurance coverage policy changes for gender-affirming care (GAC) occurred in the past decade. Several states added Medicaid coverage for GAC, and Medicare lifted its ban on gender-affirming surgery (GAS) in 2014.¹ In 2016, the Department of Health and Human Services ruled that the ACA prohibits discrimination based on gender identity in federally funded insurance plans.² Although this measure was blocked by court injunction, similar state-level measures were increasingly seen.³ Little is known about the association of these changes with access to GAS. We examined shifts in GAS by region and insurance use during periods when key antidiscrimination policies took effect.

Methods

This retrospective cohort study used data extracted from the National Inpatient Sample from 2008 to 2017. The data set included 6627 transgender patients, of whom 603 underwent GAS. Statistical models describe 3 periods when state and federal policies supporting GAS access were implemented: 2008-2013, 2014-2015, and 2016-2017. Data were analyzed from June to August 2021. This study used deidentified data and was exempted from review by the Yale University institutional review board. The study followed the STROBE reporting guideline.

Multivariate logistic regression models examined associations between GAS and patient and hospital characteristics. Characteristics were analyzed using t tests for continuous variables and χ² tests for categorical variables; individual variables were evaluated with the Wald χ² statistic. Analyses were conducted using SAS, version 9.4. Two-sided P < .05 was considered significant.

Results

Among the 603 patients, 277 (46.0%) were assigned female at birth (mean [SD] age, 36 [13.3]). During 2008-2013, self-pay was the most common method of GAS payment compared with Medicare (odds ratio [OR], 0.02; 95% CI, 0.00-0.05), Medicaid (OR, 0.02; 95% CI, 0.01-0.05), or private insurance (OR, 0.29; 95% CI, 0.20-0.43) (all P < .001) (Figure 1). Differences between self-pay and Medicare (OR, 0.27; 95% CI, 0.13-0.58; P < .001), Medicaid (OR, 0.13; 95% CI, 0.06-0.25; P < .001), and private insurance (OR, 0.57; 95% CI, 0.33-0.98; P = .04) decreased in 2014-2015; by 2016-2017, there was no significant difference between methods (Figure 1).

Before 2013, GAS was more common in the West compared with the Northeast (OR, 0.11; 95% CI, 0.06-0.19), Midwest (OR, 0.07; 95% CI, 0.04-0.15), and South (OR, 0.09; 95% CI, 0.05-0.19) (all P < .001) (Figure 2). By 2014-2015, differences decreased (ORs: Northeast, 0.18 [95% CI, 0.10-0.32]; Midwest, 0.11 [95% CI, 0.05-0.22]; South, 0.24 [95% CI, 0.13-0.44]; all P < .001) and decreased further by 2016-2017 (ORs: Northeast, 0.57 [95% CI, 0.37-0.87; P = .009]; Midwest, 0.27 [95% CI, 0.15-0.47; P < .001]; South, 0.53 [95% CI, 0.34-0.85; P = .007]) (Figure 2).

Discussion

This study found nationwide increases in GAS and a payer shift from self-pay to private or government insurance after state and federal policy changes favorable to GAS. By 2017, there was no significant difference between private or government insurance and self-pay.

Geographic disparities in GAS access diminished during the study period. Early predominance of cases in the West may be associated with state policies favorable toward GAS coverage. California was the first state to broadly expand Medicaid coverage for GAC in 2013 and had policies against discrimination in private insurance coverage.^1,4 During the study period, Medicaid coverage for GAS was introduced in 12 states and state private insurance laws became more inclusive.^1,3,5

This study is limited by reliance on ICD-9 and ICD-10 diagnosis and procedure codes, which may not represent the full range of GAS. GAS is often the final step in transition with the most stringent insurance preauthorization requirements, limiting generalizability of our results to other forms of GAC.

Despite recent improvements, access to GAS remains limited. Less than half of state Medicaid programs provide for GAC, and in 2020, only 18% of the 3 largest private health plans by state had policies favorable for facial feminization surgeries.^1,6 Policies supporting insurance coverage for GAC may have a role in expanding access to GAS.

https://jamanetwork.com/journals/jamasurgery/fullarticle/2791958