When Kelly Hanning asked state government five years ago to pay for a medical procedure she said could save her life, the answer came back: Denied.
Her appeal: Denied. A further appeal to a court: Denied.
Hanning, now 44, was used to being patient. She is a transgender woman who first saw herself as female at about age 5.
“It’s like I’ve been waiting my whole life to be who I am,” the Seattle resident said.
Now, Washington’s low-income health insurance program is poised to say yes to her latest plea by making sexual-reassignment surgery eligible for coverage.
In her youth, Hanning turned to alcohol and drugs to cope with her secret, telling no one until college. As an adult, she gradually transitioned to life as a woman, leading up to a name change a decade ago. But frustration and, at times, deep depression followed her along that path.
Hormone therapy and minor surgery helped make her comfortable in public. She’s sober, and her mental health has improved, she said. But she still feels uncomfortable in her body. It’s the wrong body, Hanning said.
“I can’t stand to look at myself in a mirror,” she said. “I don’t date because I can’t be intimate with someone the way that I want to.”
Without surgery to change that situation, a lawyer for Hanning told the state last year in petitioning for a rule change, stress about her body leaves her at risk for substance abuse and suicide.
With little fanfare, Medicaid officials responded by proposing a rule that would reverse their 2007 decision to end coverage of sexual-reassignment surgery.
It’s part of a state and national shift in how health insurance treats transgender people:
• State Insurance Commissioner Mike Kreidler — relying on anti-discrimination laws, including a 2006 state law protecting gender identity — informed private insurance companies last year they must cover transgender health care.
• The federal government overturned a policy last year against covering sexual-reassignment surgery for transgender seniors on Medicare.
• Also last year, state government agreed to cover transgender medical services for state employees.
• Some states, including Oregon, have dropped exclusions in their Medicaid programs.
Tobi Hill-Meyer has benefited from the shift toward coverage — and she says insurers have, too. The 31-year-old from Seattle grappled with a private insurance company’s refusal to cover her treatment before the company backed down.
“Not getting the medical care I needed was a really difficult time in my life,” said Hill-Meyer, an advocate with the Gender Justice League. “Having my insurance remove those exclusions turned things around 100 percent, and I’m happy, healthy and my ongoing medical costs are a lot lower than they otherwise would have been.”
Hill-Meyer is now enrolled in Medicaid, also known in Washington as Apple Health.
Apple Health already covers transgender health care short of surgery. And the state Health Care Authority that oversees the program along with state employee health care recently trained more than 1,000 employees on interacting with people who are transgender.
The authority’s proposed rule lifting the exclusion of surgical coverage could be filed in its final form as early as this month and take effect in July.
That doesn’t mean surgery would automatically be covered. It would require approval by the authority and multiple medical providers the authority deems qualified and knowledgeable about transgender health care.
Nor is it clear how widely used the new service will be. Not all transgender people seek surgery. And the number of surgeons who perform it remains small.
With the rule still under revision, questions remain about how far it will extend. Advocates came to a public hearing last month with questions and concerns about limits on coverage based on age and type of procedures covered. Officials are considering some changes and clarifications.
Transgender advocates want a range of procedures covered, including breast augmentation and hair removal. Outward physical appearance, they say, contributes to inner anguish.
No opponents of expanded coverage commented at the hearing or submitted feedback, said Gail Kreiger, a section manager at the Health Care Authority overseeing implementation of the proposed rule.
Few people may have known about it beyond those who subscribe to health care rulemaking notices. But the lack of outcry so far might also reflect a change in the political winds.
Just eight years ago, officials rewrote rules to exclude the surgery from coverage.
The Medicaid agency, then a part of the Department of Social and Health Services, reviewed medical literature and found a “lack of credible evidence in support of the procedure and and lack of consensus within the medical community regarding the procedure itself,” according to a court brief submitted by state lawyers.
While that review process was going on, operations the state had paid for came under scrutiny. State auditors questioned the spending, news stories publicized it — “State’s taxpayers paid for a sex change,” one headline announced — and Republicans in the Legislature criticized it.
Since that time, public visibility has increased for transgender people — including Olympic athlete Caitlyn Jenner, known until last week as Bruce Jenner — and acceptance has seemingly increased along with it. Medical groups, including the American Medical Association in 2008, have endorsed transgender treatment.
And this year, reaction to the Medicaid proposal from key Republicans in the Legislature was muted.
Senate Majority Leader Mark Schoesler, who in 2006 proposed cutting off funding for sexual reassignment surgery, said he still has “higher priorities for health care dollars” but that his focus is on the ongoing state budget negotiations.
Senate Health Care Committee Chairwoman Randi Becker of Eatonville said she wants to know how much it would cost and what kinds of limits are placed on the service before passing judgment on the policy. She said the authority should involve lawmakers before setting rules.
The cost implications are unclear, and the state hasn’t penciled them out.
Fifteen to 20 people have contacted the authority for information related to changing benefits, with about three-quarters interested in some kind of surgery, Kreiger said. Gender identity has been called out on claims for about 1,200 people over the past few years, she said, but not all of those would require surgery.
Of those who do, some seek chest surgery that costs as little as $5,000, according to advocates. A California doctor at one point planned to charge $22,500 for Hanning’s surgery, her lawyers told a court. A 2006 audit found the state paid more than $70,000 for one transgender patient who received surgery, but it wasn’t clear if all those costs were related to the surgery.
More people are likely to learn about the benefits through online and in-person outreach the authority is doing as it tries to get the word out that it’s “a transgender affirming agency,” Kreiger said.
Advocates said ending exclusions could actually save the state money, cutting down on emergency room visits and treatment for depression, for example.
More importantly, they say, it could save lives.
One survey found 41 percent of transgender people who responded had attempted suicide. Another survey found half of transgender people had been assaulted or sexually abused.
“I know, actually, three people who’ve committed suicide,” said Danni Askini, a social worker and executive director of the Gender Justice League. “A large part of that was the sense of hopelessness that they would never be who they want to be because of these health care exclusions.”