Health Services/Policy
The Impact Of Medicaid Coverage Of Gender-Affirming Care On Use Of Gender Affirming Surgery Among Transgender And Gender Diverse Medicaid Enrollees Alex McDowell* Alex McDowell J. Wyatt Koma Pang-Hsiang Liu Mary Beth Landrum Vicki Fung
Research Objective: Use of gender affirming care has been shown to improve health outcomes among transgender and gender diverse (TGD) adults. Many Medicaid programs have implemented policies requiring coverage of gender affirming care. However, no research has examined use of gender affirming care among TGD Medicaid enrollees or the impact of these policies on access. Using national Medicaid claims, we evaluated the impact of Medicaid coverage policies on use of gender affirming surgery among TGD Medicaid enrollees.
Study Design: We identified a sample of adult TGD Medicaid enrollees in the 2016-2019 Medicaid T-MSIS Analytic Files using a previously validated diagnosis-based algorithm. We used a difference-in-differences design to assess the impact of Medicaid coverage policies on gender affirming surgery use. Treatment states were those with no previous Medicaid coverage of gender affirming care that implemented a coverage policy between 2016-2019; comparison states were those that had implemented coverage before 2016. We estimated multivariable logistic regression models with state and year fixed effects and adjusted for age, race, and ethnicity.
Principal Findings: The number of TGD Medicaid enrollees increased from 2016-2019 from 66/100,000 (n=6,714) to 132/100,000 enrollees (n=13,351) in treatment states and from 84/100,000 (n=9,714) to 163/100,000 enrollees (n=17,620) in comparison states. Use of gender-affirming surgeries rose from 4.6/100,000 Medicaid enrollees to 30.9/100,000 in treatment states and from 22.2/100,000 Medicaid enrollees to 66.0/100,000 in comparison states from 2016-2019. In adjusted analyses, TGD Medicaid enrollees had greater odds of gender affirming surgery use after the implementation of a Medicaid coverage policy (Odds Ratio: 1.54; 95% CI: 1.37-1.74).
Conclusions: The percentage of TGD Medicaid enrollees increased about two-fold in treatment and comparison states from 2016-2019. While levels of use of gender affirming surgeries were higher in states with coverage policies before 2016, the rate of use grew more steeply among treatment states that adopted coverage policies during the study period. Our analysis suggests that Medicaid coverage of gender-affirming care increases access to and use of gender-affirming surgery.