Author(s): Christy Mallory and Will Tentindo, Williams Institute at University of California - Los Angeles

Article Type: Report 

This report highlights key factors related to Medicaid coverage of gender affirming care. Emphasis is placed on the sheer number of individuals who identify as transgender or gender non-conforming that are covered by Medicaid – about one fourth of those who identify as transgender or gender non-conforming in the United States rely on Medicaid for their gender affirming care. Underlying factors contributing to inequities for this group include unclear language about what services are covered, and/or gender affirming care services are not covered at all in their state. Authors urge all states to fully expand their Medicaid program under the Affordable Care Act. 

Author(s): Robin J. Kempf, Assistant Professor in the College of Public Service at the University of Colorado - Colorado Springs; Nicole M. Elias, Associate Professor in the Department of Public Management at John Jay College of Criminal Justice, City University of New York; Alonso J. Rubin-DeSimone, John Jay College of Criminal Justice, City University of New York

Article Type: Peer-reviewed journal 

This peer reviewed journal article describes how transgender and gender non-binary individuals have been marginalized historically in U.S. society, including in terms of institutional or informal “erasure” as well as through isolation and “hypervisibility.” In health care, this discrimination translates into lack of access to qualified professionals and lack of coverage for a continuum of needed services. Authors chose to review state Medicaid program coverage policies to identify opportunities to build equity for all U.S. residents and noted that discrimination of individuals identifying as non-cisnormative gender can be compounded by the intersectionality of race, sexual orientation, socioeconomic status, and geographical location. They assessed comprehensiveness of state Medicaid coverage in accordance with the World Professional Association for Transgender Health (WPATH) standards. Authors found that the five states in their sample varied widely in terms of health coverage to transgender and gender non-binary Medicaid beneficiaries, however, there were stand out states in terms of the continuum of services offered as well as opportunities for improvement. Authors recommend removal of barriers to needed care such as prior authorization requirements as well as additional training for providers and individuals making coverage determinations.

Author(s): Nance Yuan, Cedars-Sinai Transgender Surgery and Health Program, and member of the Urology and Plastic Surgery Divisions at Cedars-Sinai Medical Center; Theodore Chung, David Geffen School of Medicine, University of California, Los Angeles; Alma Jimenez-Eichelberger and Caitlin Sioni, Cedars-Sinai Transgender Surgery and Health Program and the Division of Urology at Cedars-Sinai Medical Center; Edward C. Ray, Division of Plastic Surgery, Cedars-Sinai Medical Center; Maurice M. Garcia, Departments of Urology and Anatomy, University of California, San Francisco 

Article Type: Peer-reviewed journal 

This peer reviewed article investigates and discusses insurance requirements for referral letters from mental health providers prior to genital gender affirming surgeries for trans and non-binary individuals. In this study, half of the participants had federally funded insurance, such as Medicaid. Most plans, both public and private, required at least two referral letters at every stage of surgery (there may be four to five stages depending on the operation). Authors state that it took office staff, “an average of 2.5 hours per patient, per surgery, dedicated to coordinating submission of updated referral letters”. Some participants had to cancel or reschedule an operation due to lack of coordination of care, and/or administration not receiving referral letters. This resulted in patients being forced to pay for surgeries out-of-pocket instead of using insurance coverage. The authors discuss how multiple letters for each stage of a surgery is unnecessary, when no participant was deemed mentally unfit for any previously performed procedure. Authors state that requiring updated letters for each year was also a point of stress for participants as these administrative burdens were “costly and burdensome” to patients and providers alike. The authors urge organizations such as the World Professional Association for Transgender Health (WPATH) to revisit their recommendations for referral letter requirements to alleviate the burdens on both administrators and patients alike.

Author(s): Samuel Mann, Christopher S. Carpenter, Benjamin Harrell, and Cameron Deal are all from the Department of Economics, LGBTQ+ Policy Lab, Vanderbilt University, Nashville, Tennessee; Gilbert Gonzales is also a member of the Department of Medicine, Health & Society, and Department of Health Policy at Vanderbilt University. 

Article type: Peer-reviewed journal 

This peer reviewed journal article analyzes how Medicaid expansion influenced health insurance coverage for individuals in same-sex partnerships. Using data from the American Community Survey, authors found that there was a significant increase in coverage between 2009 and 2018 for low-income adults who were in a same-sex relationship, especially for women. The authors attribute this to a much higher prevalence of children being in households of women same-sex couples compared to men. The authors also state that sexual minority women may have stronger social ties that reduce stigma surrounding Medicaid or public options compared to sexual minority men. This research has implications that are important for policymaking and underlying factors of inequity within Medicaid in terms of barriers to seeking health insurance coverage and accessibility of services for those individuals in same-sex partnerships. 

Author(s): Carli Friedman, Director of Research for The Council on Quality and Leadership (CQL) at the University of Washington; Laura VanPuymbrouck, Assistant Professor of Occupational Therapy at Rush University

Article Type: Peer-reviewed journal

This peer reviewed article summarizes findings from a quantitative study exploring the association between ableism in the U.S. and Medicaid spending on long term services and supports. It begins with historical context about deinstitutionalization of people with disabilities and the history of Medicaid as both a primary payer for long-term care and an insurer for people with disabilities. Despite research indicating community living has more benefits than institutions, investments in home and community-based services vary state to state; authors hypothesize that an association exists between stereotypical attitudes toward people with disabilities (i.e., as dependent, a drain, not capable) and state decision making. Using CMS expenditure data and survey data from the Disability Attitudes - Implicit Association Test, authors found a negative association between state prejudice scores and state funding of home health and community-based services. While causality cannot be assumed, authors conclude by stressing the importance of understanding how disability prejudice is embedded into our society, and how it may influence Medicaid and other policy decisions. These findings are a call to advocate for increased investment in community services and to promote advocacy for the health and well-being of people with disabilities.

Author(s): Emmalise Earl, Seton Hall University, Judicial Law Clerk in New Jersey Court System

Article Type: Peer-reviewed journal

This article discusses long-standing systemic issues with having accessible health care tools and equipment for people with physical disabilities. Despite the passage of the American Disabilities Act in 1973, which requires hospitals and clinics to have physically accessible equipment for care for all individuals regardless of mobility status, the Act has gone loosely enforced for decades according to the author. Lack of accessible equipment for routine checkups, such as scales and exam tables, results in incomplete examinations, later and more severe diagnoses due to inability to screen those with mobility related disabilities, as well as an exacerbation of current diagnoses due to incomplete or less effective treatment. The author states that “without more aggressive enforcement, these circumstances are not likely to change”. The author uses the Department of Veterans Affairs (VA) hospitals as an exemplar for what is needed to uphold accessibility standards. The VA requires all new medical equipment to be approved as accessible by their Access Board. The author also describes specific program actions that the Center for Medicare and Medicaid Services needs to take in enforcing equitable access to medical equipment. For Medicaid in particular, the author suggests that state Medicaid agencies adopt and enforce standards that facilities and providers must follow in order to participate in the Medicaid program. The authors also suggest leveraging tax incentives to overcome financial barriers to accessibility.

Author(s): Rupa S. Valdez, the Departments of Public Health Sciences and Engineering Systems and Environment, University of Virginia; and Bonnielin Swenor, the Disability Health Research Center, Bloomberg School of Public Health, Johns Hopkins University

Article Type: Peer-reviewed journal perspective

This article discusses the details of systemic ableism and its effects on those with intellectual and/or physical disabilities. The authors maintain that this underlying factor of health inequities is often ignored in health care and research spaces. In addition, more attention is needed on the ways structural ableism interacts with other forms of oppression. The core purpose of this article is to highlight achievable and actionable solutions for alleviating bias and discrimination of those with disabilities. Proposed solutions include establishing measures of structural ableism within research and providing accessibility options within physical environments (e.g.  streets & roadways, buildings, neighborhoods, and cities). The authors also emphasize a need for the adaptation of measures of structural racism plus the addition of new measurement domains. Of particular importance for the authors is measuring both the funding allocated for home and community based services within the Medicaid program as well as measuring the rate of violations of the Olmstead decision, which entitles those with disabilities to community integration and community-based services. Consideration of qualitative methods and community partnership in this work is also crucial for creating actionable and effective solutions to issues of systemic ableism.