Almost three weeks after Florida’s Republican governor, Ron DeSantis, signed a bill making it a felony for doctors to provide gender-affirming care to transgender minors, a judge issued a preliminary injunction preventing enforcement of the law for three children whose parents are part of an ongoing lawsuit.

Florida is one of at least 20 states that have . The legislators sponsoring some of these bills say their intent is to protect children and families from pressure “to receive harmful, experimental puberty blockers and cross-sex hormones and to undergo irreversible, life-altering surgical procedures,” as puts it.

“Gender transitions involving major surgeries not only result in sterility, but other irreversible negative biological effects,” said Montana state Sen. John Fuller, the Republican who introduced the bill.

Such laws and policies, and statements — such as Fuller’s — used to justify them, reflect misconceptions and misinformation that conflate treatments and strip trans youth of essential care.

Gender-affirming care is a broad term for many distinct treatments provided to children, teens, and adults. Puberty blockers, for example, are medications that inhibit puberty by suppressing the body’s production of sex hormones, while hormone therapy is the administration of testosterone or estrogen to alter secondary sex characteristics.

One common misbelief heard when legislation is discussed is that gender-affirming medical interventions are provided immediately to any trans or nonbinary kid who walks into a gender clinic.

The reality is that the process informing these treatments is a long and intensive one. Before any medical or surgical interventions, kids must first be , which, for prepubescent youth, involves experiencing significant distress for at least six months from at least six of a set of causes, including a strong desire to be of the other gender and a strong dislike of one’s sexual anatomy. Youth who have gone through puberty must meet two of the criteria for a diagnosis.

Providers also abide by the standards of care set by the World Professional Association for Transgender Health. These standards to perform a comprehensive assessment of a child’s or teen’s “strengths, vulnerabilities, diagnostic profile, and unique needs” before providing any medical or surgical interventions. Without this assessment, other mental health issues “that need to be prioritized and treated may not be detected.”

The time it takes to perform this assessment varies from patient to patient, said Jack Turban, an assistant professor of child and adolescent psychiatry at the University of California-San Francisco. Turban may see someone who is 12 years old and asking for puberty blockers. This hypothetical patient has known they are trans since they were 5 years old and has already adopted a new name and pronouns that match their gender identity.

“That’s going to be a much shorter assessment to know that they are ready for treatment when compared to somebody who has only understood their trans identity for six months” and has other complex mental health conditions like schizophrenia, Turban said.

To receive puberty blockers, kids must also have experienced the onset of puberty, or on the Tanner scale of developmental change. This is marked by physical changes like the development of breast buds or testicle growth and tends to happen between the ages of 9 and 14 in kids with testes and 8 and 13 in those with ovaries. By pausing puberty, these drugs buy children more time to explore their gender identity before undergoing permanent and potentially unwanted pubertal changes.

The age at which trans minors receive gender-affirming hormone therapy depends on the patient’s ability to provide informed consent for the treatment, which can happen when they’re as young as 12 or 13 years old. The Endocrine Society notes that to consent by the time they’re 16.

“We offer hormones to patients who are experiencing gender incongruence when patients and families are ready. This may be at an earlier age so that patients can go through puberty alongside their cisgender peers, or later, if they choose to,” said Mandy Coles, co-director of the Child and Adolescent Transgender Center for Health at Boston Medical Center. “If someone says, ‘I’m interested in estrogen,’ I say, ‘Great. What are the things that you are hoping to get out of that?’ Because it’s incredibly important to speak to patients and families about what medications can do, and what they can’t do.”

Coles said she also makes sure to talk continuously about consent with both the child and parents throughout the treatment process and lets her patients know they can stop taking hormones at any time.

Some physical changes by gender-affirming hormone therapy are reversible. For example, decreased muscle strength and body fat redistribution caused by estrogen can reverse once a person stops taking the hormone — though these changes become more fixed the longer someone stays on the hormone. However, breast growth from estrogen or a deepening of the voice caused by testosterone are not reversible.

If a trans person decides to receive gender-affirming surgery, clinics require that the individual receive letters from one or more providers stating they have persistent and well-documented gender dysphoria, any significant mental health concerns they have are sufficiently controlled, and they can consent to the surgery. For genital, or “bottom,” surgery, the letter may also need to state that the individual has been living full time in their “identified gender” for at least 12 months.

Most medical centers require individuals to be at least 18 years old for bottom surgery and chest, or “top,” surgery, though some do perform top surgery on younger teens if the patient, their parents, and health care providers agree the procedure is appropriate.

Much of the confusion is over puberty blockers, drugs that have been used for decades for children who enter puberty too early. A common assertion anti-trans groups and legislators make is that puberty blockers are dangerous and lead to infertility. This is not the case, said Coles. “Puberty blockers are fully reversible medications. They work like a pause button on puberty.”

Fertility may be impaired, however, in those who go straight from puberty blockers to hormone therapy, which is why the current medical guidelines require fertility counseling prior to any gender-affirming medical care, said Turban.

The FDA has not approved the use of puberty blockers for gender-affirming care. However, across all medications are for “off-label,” or unapproved, use — and the rate is even higher for prescriptions to children.

“We know that taking away the decision to use blockers from parents and providers leads to poor health outcomes for patients,” said Coles.

A study by Turban and colleagues found that trans adults who received puberty blockers during adolescence were than those who wanted puberty blockers but did not receive them.

The same benefits have been found with gender-affirming hormone therapy.

In a study of data from nearly 28,000 trans adults who responded to the , Turban and fellow researchers found that people who received gender-affirming hormone therapy during adolescence had than those who didn’t take hormones until they were adults.

Additionally, a study of 104 young trans and nonbinary patients at the Gender Clinic of Seattle Children’s Hospital found those who had started on puberty blockers or hormone therapy had of depression and 73% lower odds of self-harm or suicidal thoughts than peers who hadn’t received those treatments.

There is so much misinformation claiming that providers of gender-affirming care are permanently harming vulnerable children, said Coles. “Denying access to care harms transgender and gender-diverse kids,” she said. “Gender-affirming care is not new. It’s the attacks on care that are new.”

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A closer look reveals that Hilltop Day Treatment is no ordinary school. There are no backpacks or lockers. Students are escorted to the restroom. Hugs aren’t allowed, a precaution against inappropriate touching by students who do not yet understand physical boundaries. And before lunch, the students break from their regular lessons for group therapy.

Hilltop is a facility school, Colorado’s term for specialized institutions that serve students with severe behavioral, mental health, or special education needs when their public schools can’t. And this school, with 12 students, is the last of its kind on the Western Slope, the vast territory west of the Continental Divide of the state’s population. The other are in the more heavily populated Front Range corridor.

“It breaks our heart to have a waitlist,” said Hollie VanRoosendaal, director of community programs at Hilltop Community Resources, the organization that runs the Hilltop Day Treatment school. “We really want to get those kids in and seen and getting their education towards their graduation as well as some really great therapeutic services.”

Disability rights and mental health advocates say facility schools are overused and can become dumping grounds for students with disabilities. But in rural Colorado, when the local school district can’t meet a student’s needs, the lack of spots in facility schools can mean students end up at home learning online, languishing in mental health facilities, or attending a residential school far from home.

Democratic Gov. Jared Polis signed a bill into law this spring that provides funds to prop up facility schools and strengthen services for students with severe needs in rural districts. But the sparse population and vast distances of the Western Slope and eastern plains mean serving these vulnerable students will likely remain a challenge.

“There are no services there. And so you get one student with autism that comes into this little tiny district, what’s going to happen? That child is not going to get what he or she needs, and they’re too far away from the Front Range,” said Barb Taylor, an educator turned consultant who serves as special education director for several Colorado facility schools.

According to , among the main reasons students could not be placed at a facility school were lack of openings and, in rural areas, “prohibitive geographic location.”

A few rural patches of the state have figured out alternatives to serve students closer to home. For example, the Santa Fe Trail Board of Cooperative Educational Services, or BOCES, started the in La Junta for students in the eastern plains with emotional and behavioral problems.

But few other BOCES, that pool resources to provide services they would not be able to alone, have managed to start such programs.

Instead, across much of rural Colorado, “we have people that are trying to work with these kids that are not qualified or that are not trained, that don’t have the skills that they need to be able to do that in the district,” said Sandy Malouff, executive director and special education director of the Santa Fe Trail BOCES.

In the western half of the state, Sonjia Hunt, director of Hilltop Day Treatment school, said she has watched facility schools scale down or close: first in Rifle, then in Whitewater, Delta, Durango, and, last year, one .

After operating in the red for years, Hilltop had to scale back as well, shutting down its 16-bed residential facility in October 2020. Now, students on the Western Slope who require residential treatment must travel across the Rockies, if not out of state, Hunt said.

The new state law will allow Hilltop to hire another teacher, case manager, and therapist, and take on 12 more students, Hunt said. But Hilltop doesn’t plan to reopen its residential side.

When the residential facility closed, surrounding communities struggled to make up the loss, said Tammy Johnson, executive director of the Uncompahgre BOCES, which serves five rural western districts.

“There’s a big difference between being an educational entity and a therapeutic entity. We just don’t have the training that we need to meet these kids’ needs,” said Johnson.

‘I Just Needed Help’

Riley George, a 12-year-old with autism and disruptive mood dysregulation disorder, has had to cross a mountain range to get an education. After enrolling in and leaving multiple schools, Riley now lives in a residential facility in Colorado Springs, more than three hours from his home in Del Norte.

The slight preteen, whose tufty hair sticks up in the wind like a thistle, is an avid reader who tears through 400-page science fiction books. He loves his dog and Baby Yoda, a character from the Star Wars TV series The Mandalorian. He goes for walks with one of his little sisters and plays action figures with his little brother. On a good day, said his mother, Kelly George, he’s “a good, respectful kid” who has no trouble getting himself ready for school.

But Riley’s brain works faster than his hands, which can make tasks like writing or tying shoelaces feel frustratingly insurmountable. He is only now learning how to play make-believe with others cooperatively, something other children tend to learn at a much younger age. And seemingly small things, like an itchy tag on his clothes, or loud noises, like his sister’s happy shrieks, can send him to a bad place.

“When he was younger, he would cover his ears and just immediately hit the floor and start screaming like he was in pain,” said George.

Now that he’s older, overload leads to aggression: hitting, cursing, kicking. “We had to design a code word for the other kids,” said George, to signal to her three younger children to barricade themselves in a room while the parents try to calm the eldest.

From preschool through second grade, Riley attended Bill Metz Elementary School in Monte Vista, one town over from where his family lives. Riley remembered how his teachers there gave him space when he was upset, as on the day his dog ran away. His special education teacher, Kellyn Ross, remembered him complimenting the cafeteria staff for a “divine” lunch.

Riley was in the Pokémon Club and could earn points for good behavior that he could redeem for prizes. Riley and Ross developed a system to help him identify his feelings and others’, and to take a break when needed.

Monte Vista School District Superintendent Scott Wiedeman said the school takes a to encouraging positive behavior in all students.

But when Ross got a promotion, the school couldn’t find someone with enough experience to fill her spot, and they were at capacity with special education students. In the decade since Ross had started as a special education teacher, her caseload had doubled. So, they had to send out-of-district students, including Riley, back to their neighborhood schools.

“The kicker is just having the resources,” Wiedeman said. “We need more people to deal with the mental health of students. That’s a big factor.”

After that, Riley started lashing out at others. The calls home ratcheted up, as did the use of force at school to restrain him.

When Riley was in third grade at Del Norte Elementary, he was on an individualized education program for serious emotional disability. Despite that, school officials frequently suspended him and whittled his classroom time down to one hour a day, the Georges said. When school districts shortened their special education students’ school days due to behavior, experts determined it was as counterproductive as limiting reading time for students who are struggling to read well.

Aaron Horrocks, superintendent of the Upper Rio Grande School District, declined to comment on Riley specifically but said challenging behaviors are on the rise and schools need more support services and options — funding to hire paraprofessionals or a day treatment center within driving range.

One day, Riley slapped the side of the school bus and cursed, his mother said, and school staffers held him on the ground for an hour — Riley said one sat on him. The Georges filed a civil rights complaint with the U.S. Department of Education that alleged school officials had discriminated against Riley because of his disability. The department acknowledged that IEP documents show Riley was physically restrained three times over the course of a month.

Before an investigation got underway, the school district settled the complaint by adopting new protocols and training staff members on shortened school days and physical restraints. The Georges eventually chose to take Riley out of that school and enroll him in an online school.

That worked for about a year, with his father, Matthew George, staying home to help with schooling while Kelly George became the sole breadwinner.

But when Riley gave his mother a bruise the size of two softballs — and threatened to kill her while she slept — they were stuck: He had to go somewhere that could meet his needs, for his family’s safety. They contacted several residential facilities and even a few hospitals but ran into a string of denials: Some didn’t accept his insurance; others rejected him because he wasn’t yet a teenager, because of his aggressive behavior or his autism, or because they just had no beds left.

Schools in Utah, Arkansas, and Texas didn’t respond, and there was no room in Wyoming. By that point, Hilltop had closed its residential program, and driving more than four hours each way for a day program was out of the question.

In the meantime, Riley was in and out of short-term treatment facilities on multiple emergency mental health holds between September and January. , emergency holds allow people to be kept for 72 hours for treatment and evaluation if they appear to be an imminent danger to themselves or others.

When Kelly George called her county’s social services department, she said, the response was that “unless he basically puts me in the hospital or is really aggressive towards one of his siblings and actually hurts them, there was nothing they could do, because it’s not an abuse or neglect case.”

So, they pressed assault charges against their own child.

“I just needed help, and it was the last card I could play,” said Kelly George.

Breaking the Cycle of Anger

Critics of facility schools condemn their segregated nature, but Riley wound up in even more segregated places over the next four months while his family tried to secure a bed at a residential school. After being criminally charged, Riley first went to , a detention facility. That was followed by a stint in a mental health hospital. His belongings moved with him in a garbage bag — the “essentials,” said Riley, plus 10 books about the military sci-fi franchise Halo.

Then, in late March, the Georges drove him to a Colorado Springs facility school called the J. Wilkins Opportunity School.

“I want to learn to control my anger better,” Riley said on his first day there. He missed his dog. He said he’d be ready to go home when anger no longer feels like “clenched fists.”

The Georges wish there were a place closer to home. “We can’t be the only family in our 200 square miles dealing with this,” said Kelly. A dream scenario, she said, would be to have a school that kids like her son could attend, with transportation to and from school, and therapeutic support at home.

Some provisions in the new Colorado law are intended specifically to help rural areas, such as establishing a statewide technical assistance center to help meet rural students’ needs.

It could provide anything from in-person training for school staffers to a behavior analyst available to coach people over the phone in a pinch, said Malouff, the Santa Fe Trail BOCES executive director, who participated in a that came up with the idea. The details have not yet been determined.

Malouff hopes the center will help rural districts gain the skills they need to keep students at home, and free up facility school spots for others with more severe needs.

Michelle Murphy, executive director of the Colorado Rural Schools Alliance, and others in rural education are skeptical that a single statewide technical assistance center can provide the support districts need when so much of the need is for boots on the ground.

“We have workforce challenges in virtually every aspect of our special education programs, from teachers to our special service providers to our paraprofessionals,” said Murphy. “It’s close to, if not an actual, crisis at this point.”

Pat Bershinsky, executive director of the Pikes Peak BOCES in Colorado Springs, said rural needs would be more effectively met if the money instead went directly to BOCES to create their own programs.

The Georges would have kept Riley at or close to home had they been able to get the right training, services, and support. In states like Minnesota, for example, it’s possible to at home under certain circumstances, including for help with frequent aggressive behaviors for a home-schooled student with an individualized education program.

Such services were created to keep people in their communities and avoid institutional placement. Colorado does not appear to offer such services specifically geared toward aggressive behavior.

On move-in day in Colorado Springs, the Georges toured the campus with Riley and carried his belongings into his new room. Matthew George excitedly pointed out that Riley will be living mere blocks from a U.S. Olympic & Paralympic Training Center.

“I can’t believe that, finally, after all this time — eight months — it’s finally happening and my family’s needs are finally, finally being met,” said Matthew George. But he was also apprehensive. He, too, was institutionalized as a child, bouncing for five years between foster care and the same mental health hospital and facility school organization as his son.

“I never thought I would be in a position where I would be an adult and witness my son going through the same things that I went through,” he said. “Something really needs to be done, because I don’t want to be going and visiting my grandkids in a facility like this.”

Riley’s move has the Georges’ other children worried, too. Kelly George recalled their 5-year-old daughter throwing a temper tantrum over ice cream, then wailing in fright: “I’m gonna get sent away! I don’t wanna get sent away.” But Kelly, too, is optimistic about Riley’s new chapter.

“It’s sad that we’re leaving him here, but at the same time I’m really hopeful that this is going to be what he needs to get him to where he can be OK and be at home with us,” she said.

When it was time to say goodbye, Matthew George hugged his son close. “You can do this,” he told him. And then the family drove away, back through the mountains, back home.

Chalkbeat Colorado senior reporter Melanie Asmar contributed to this report.

about last resort

“Last Resort” is a Colorado News Collaborative-led four-part investigation by Chalkbeat Colorado, The Colorado Sun, and Â鶹ŮÓÅ Health News into the collapsing system of schools that serve some of Colorado’s most vulnerable students.

The state is now scrambling to shore up what are known as facility schools, which each year enroll thousands of students with intense mental and behavioral health needs.

The complete series .

Part 1: The schools that take Colorado’s “most vulnerable” students are disappearing.

Part 2: Students in rural Colorado are left without options as specialized schools close.

Part 3: Colorado is now pouring more money into facility schools, but are they helping?

Part 4: How Colorado is filling gaps as last-resort schools dwindle.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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Colorado is one of 10 states where laws don’t , according to the American Heart Association. In February, the Colorado House passed to add training for CPR and how to use an automated external defibrillator, or AED, to the Colorado Department of Education’s comprehensive .

But the proposal stops short of requiring public high schools to adopt the revised curriculum, or subsidizing the effort. Instead, they would be strongly encouraged to implement the training on their own.

“The bill is a noble effort and is something that needs to be done,” said Lynn Blake, vice chair of the Eagle County Paramedic Services board. “However, it’s a feel-good law until mandates and dollars accompany it.”

In 2021, Colorado reported 3,727 cases of cardiac arrest — in which the heart abruptly stops beating — to the , or CARES, which tracks incidents occurring outside hospitals. This number is likely an underestimate, as the data was collected from less than 80% of the population. Last summer, Colorado became the first state to establish an office within its state health department dedicated to and finding ways to increase survival rates.

Nearly experienced outside of a hospital are fatal, according to CARES. CPR a person’s chance of survival if performed immediately after the heart stops beating.

So, the more bystanders who know how to administer CPR, the better, said Blake, who was 27 when she was stricken by cardiac arrest. A woman nearby performed CPR on her, and a few minutes later, paramedics arrived and shocked Blake three times with an AED, which saved her life. A 2022 study by the Children’s Hospital of Philadelphia found that states that require CPR training in schools have higher rates of CPR being performed by bystanders, thus .

“We have a huge need for people to learn to act quickly in emergency situations,” said state Sen. Janice Marchman, a Democrat sponsoring the bill. “That’s why it would be great to train high school students not just to do CPR, but also to use the AED machines.”

The bill encourages each public school to adopt a curriculum that includes “hands-on” training on performing CPR and using a defibrillator. However, the proposal doesn’t allocate money to school districts to support the training, according to the . A single CPR manikin and AED trainer together cost around $600, according to the American Red Cross store. School districts might be eligible to apply for a , funded by the state education department, to help pay for lessons, Marchman said.

The bill also stops short of making CPR training a graduation requirement for public high schools, leaving Colorado an outlier while 40 other states plus Washington, D.C., command it. Alabama has mandated CPR training for high school graduation , and Iowa has done the same .

All Colorado public schools are bound by the state’s comprehensive health academic standards, so it’s likely that most schools would abide by the change without making it a graduation requirement, Marchman said.

Colorado Senate Republicans are confident schools will be eager to equip students and teachers with these lifesaving skills, caucus spokesperson Joshua Bly said.

The Colorado Department of Education’s role is to implement policy, not speculate on why CPR and AED training is not mandated in high schools, department spokesperson Erica Grasmick said.

This isn’t the first time Colorado lawmakers have sought CPR training in high schools. A pushed by the American Heart Association tried to mandate CPR and AED training for high schoolers. But the Colorado Association of School Executives , as its members argued that school districts should be able to “decide what is important at a local level” as they are “tasked with the difficult job of balancing budgets.”

Not mandating CPR and AED training in high schools is a significant loss, said Blake. “If I was the author of the bill, I would require that all students and administrators, teachers, coaches — anyone who is involved with any kind of education — to be trained in CPR,” she said.

Still, Blake sees this bill as a step in the right direction. “Stakeholders are eager to return to the Capitol in coming sessions with an even more robust bill, including CPR and defibrillator requirements and funding,” she said.

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would cap out-of-pocket copays at $60 for a two-pack of epinephrine autoinjectors. In 2007, the wholesale was about $47. Today, just under $636 at a Walgreens in Denver, according to GoodRx. At some pharmacies , which is still expensive for many people.

The bill is the latest example in a nationwide push by states to address the soaring prices of lifesaving drugs. New Hampshire passed a law in 2020 , and Rhode Island lawmakers this year. No state has capped what consumers pay for EpiPens, though the New Jersey Senate in June to do so; that measure is pending in the legislature’s lower house.

The average launch prices of drugs in the United States increased , according to a study published last year. Price increases can skyrocket even higher for items such as epinephrine autoinjectors, a market dominated by EpiPen maker Viatris, a global pharmaceutical company.

“If you have very little competition in the market, the way the U.S. drug pricing system works is that the manufacturers get to set the price at which they want to sell the drug, and they can increase it whenever they so choose,” said Erin Taylor, a senior health care policy researcher at Rand Corp., a global policy think tank. “One way to shift costs back to health plans and manufacturers, and to help patients pay less for their drugs, is to apply these caps.”

The Colorado legislation would cap EpiPen copays for both insured and uninsured people starting in 2024. Almost 566,000 Coloradans have life-threatening food allergies, according to the bill. People can also have severe reactions to insect bites, medications, and latex.

“The need for EpiPens doesn’t discriminate based on who you are,” said state Rep. Iman Jodeh, a Democrat who is sponsoring the bill. “This unfortunate trend we were seeing of lifesaving medication being completely unattainable or out of reach for people is something that we are really trying to put an end to.”

In 2019, Colorado became the first state to enact a law that set a $100 , a hormone that regulates the blood sugar of people with diabetes.

Since then, , have implemented laws limiting insulin costs. Congress imposed a $35 insulin copay cap for seniors on Medicare, and, in his recent State of the Union address, President Joe Biden called for .

“Insulin has been the poster child of copay caps,” said Geoffrey Joyce, director of health policy at the University of Southern California Schaeffer Center for Health Policy & Economics.

However, the caps are an imperfect solution to high prescription costs. Decreasing the price of a drug for some insurance members means increasing premiums for others, said Taylor. “A cap doesn’t lower the list price of the drug, so somebody else has to pick up the difference,” she said. Caps also don’t address why drugs are so expensive in the first place.

Drug manufacturers and pharmacy benefit managers, or PBMs — the go-between companies that negotiate with drugmakers on how much insurance plans and consumers will pay for drugs — both play a significant role in drug pricing, Joyce said. Besides pricing their products high enough to ensure a hefty profit, manufacturers often give PBMs a rebate in exchange for having their product included in the PBM’s list of preferred drugs, which influences what consumers buy. Rising rebates demanded by PBMs are for prescription drugs, according to a white paper by USC Schaeffer.

“Everybody has their hand in the trough,” said Joyce. In response to broader concerns about the drug pricing system, diabetes activists have been pushing for caps on insulin prices, not just copays.

It’s hard to say whether more states will follow Colorado’s lead and cap out-of-pocket costs for drugs like EpiPens, but there does seem to be a political appetite for controlling specialty drug costs, said Taylor.

“It bothers people fundamentally and ethically that these lifesaving drugs are inaccessible for people,” said Joyce. “People need access to these drugs.”

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The number of reports the Rocky Mountain Poison and Drug Safety office received of kids age 5 or younger exposed to marijuana in 2021. By 2021, this age group made up nearly half of all marijuana exposures — in which the drug is ingested, inhaled, or absorbed through the skin — reported to the office, which is part of the nonprofit Denver Health organization.

In each of those five years, children were most often accidentally exposed by eating edibles — gummies, cookies, drinks, and other products infused with the psychoactive chemical tetrahydrocannabinol, or THC — and not by inhaling smoke or consuming the drug in other forms, like capsules or tinctures. In 2017, 35 children age 5 or younger were unintentionally exposed to marijuana through edibles, compared with 97 in 2021. Exposures don’t necessarily mean the children were poisoned or overdosed, according to the poison and drug safety office.

Marijuana exposures among children are increasing nationwide, with Colorado playing a notable role in this trend. However, the federal government has yet to create uniform protocols, and Colorado health officials haven’t conveyed any plans to revise the regulations meant to prevent children from consuming marijuana.

“Marijuana laws and regulations are regularly evaluated by lawmakers, state agencies, local agencies and the various stakeholders,” Shannon Gray, a spokesperson at the Marijuana Enforcement Division, which regulates the marijuana industry in the state, wrote in an email to KHN. “A top priority is preventing youth access and to the extent we see opportunity in rules to address youth access, we do so.”

Since legalized recreational marijuana sales began in 2014, Colorado has implemented a handful of directives to stop children from mistaking these products for safe, delicious sweets.

Regulations state that:

• No edibles may be manufactured in the shape of a human, an animal, or a fruit.
• All edibles must be sold in child-resistant packaging.
• “Candy” or “candies” isn’t allowed on packaging.
• Advertising must not include cartoon characters, or anything else meant to appeal to children.
• The universal THC symbol (! THC) must be on all packaging and stamped on all edible products.

Data from Rocky Mountain Poison and Drug Safety does not distinguish between incidents involving marijuana sold by licensed retailers and those involving marijuana from sources that don’t follow the state’s packaging rules, state health department spokesperson Gabi Johnston told KHN.

When asked whether the mandates are effective, Gray said the Marijuana Enforcement Division has “observed material compliance with these regulations” among marijuana businesses.

Regulation changes could be considered, including those proposed by state legislators, Gray said. But no forthcoming bills concern edible mandates, according to Jarrett Freedman, spokesperson for the Colorado House of Representatives majority. Democrats control both houses of the state legislature.

One limitation of regulating marijuana packaging is that most children 5 and younger can’t read, said Dr. Marit Tweet, a medical toxicologist at the Southern Illinois University School of Medicine. And, she said, many parents don’t know how to store marijuana safely.

The state health department has worked to address this knowledge gap through its , established in 2014 to teach the public about safe, legal, and responsible cannabis use. One fact sheet advises parents to store marijuana in a locked area, keep products in child-resistant packaging, and avoid using marijuana around children.

Public health officials also launched in 2018 targeting new parents and adults who influence kids’ behavior. Between fiscal years 2015 and 2020, the department spent roughly $22.8 million on those efforts.

It’s hard to say exactly how well marijuana regulations in states like Colorado are working, said Tweet. “It’s possible if those regulations weren’t in place that the numbers would be even higher.”

What’s happening in Colorado is part of a national trend. In a study published in January, researchers looked at the number of children younger than 6 who ingested marijuana edibles nationwide from 2017 to 2021. They found 207 reported cases in 2017. In 2021, , according to data from the National Poison Data System.

The legalization of cannabis has likely played a significant role in the rise of accidental child exposures, said Tweet, a co-author of the study. “It’s more readily available and more of an opportunity for the children to get into.”

Parents may also feel less stigma nowadays in reaching out to poison centers and health clinics, she said.

To understand what factors are driving these numbers, more research is needed into marijuana regulations and the number of child exposures nationwide, said Tweet.

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As a transgender woman, Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’”

So Rainey drives around 170 miles round trip every six months to get a supply of estrogen from a clinic in Memphis, Tennessee, to take home with her.

The obstacles Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural U.S. often face: a general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama-Birmingham.

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states in the U.S. live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, , a nonprofit think tank at the UCLA School of Law.

One in 3 trans people in rural areas in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. Additionally, a third of all trans individuals report having to teach their doctor about their to receive appropriate care, and 62% worry about being negatively judged by a health care provider , according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as all transgender adults to .

In Colorado, for example, many trans people outside Denver . Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first . As of 2018, 76% of medical schools included , with half providing three or fewer classes on this topic.

Perhaps because of this, almost in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use .

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or , has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Dr. Caroline Kirsch, director of osteopathic education at the University of Wyoming Family Medicine Residency Program-Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide . For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the . After growing pressure from Tennessee’s Republican lawmakers, the clinic on patients younger than 18, potentially leaving many trans kids without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”

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Electrolysis is a common procedure among transgender people like Chevalier, a software developer in Oakland, California. In some cases, it’s used to remove unwanted hair from the face or body. But it’s also required for a phalloplasty or a vaginoplasty, the creation of a vagina, because all hair must be removed from the tissue that will be relocated during surgery.

Chevalier’s insurer, Anthem Blue Cross, told him he needed what’s known as a prior authorization for the procedure. Even after Chevalier received the authorization, he said, his reimbursement claims kept getting denied. According to Chevalier, Anthem said the procedure was considered cosmetic.

Many trans patients have trouble getting their insurers to cover gender-affirming care. One reason is transphobia within the U.S. health care system, but another involves how medical diagnoses and procedures are coded for insurance companies. Nationwide, health care providers use a list of diagnostic codes provided by the International Classification of Diseases, Tenth Revision, or ICD-10. And many of those, advocates for transgender people say, haven’t caught up to the needs of patients. Such diagnostic codes provide the basis for determining which procedures, such as electrolysis or surgery, insurance will cover.

“It’s widely regarded that the codes are very limited in ICD-10,” said Dr. , medical director of the at Children’s Hospital Los Angeles.

She advocates for a move to the 11th edition of the coding system, which was endorsed by the World Health Organization in 2019 and began to be adopted around the globe in February. Today, more than .

The new edition has like “transsexualism” and “gender identity disorder” with “gender incongruence,” which is no longer classified as a mental health condition, but as a sexual health one. This is crucial in reducing the stigmatization of trans people in health care, said Olson-Kennedy.

A move away from the mental health classification may also mean more coverage of gender-affirming care by insurance companies, which sometimes question mental health claims . WHO officials have said they hope that adding gender incongruence to a sexual health chapter will “help increase access to care for health interventions” and “destigmatize the condition,” .

However, history suggests that ICD-11 likely won’t be implemented in the U.S. for years. The WHO first endorsed ICD-10 in 1990, but the U.S. didn’t implement it for .

Meanwhile, patients who identify as transgender and their doctors are spending hours trying to get coverage — or using crowdfunding to cover big out-of-pocket bills. Chevalier estimated he has received 78 hours of electrolysis at $140 per hour, costing $10,920.

Anthem spokesperson Michael Bowman wrote in an email that “there has been no medical denials or denial of coverage” because Anthem “preapproved coverage for these services.”

However, even after the preapproval was given, Anthem responded to Chevalier’s claims by stating the electrolysis would not be reimbursed because the procedure is considered cosmetic, rather than medically necessary. This is regardless of Chevalier’s diagnosis of gender dysphoria — the psychological distress felt when someone’s biological sex and gender identity don’t match — which many doctors consider a medically legitimate reason for hair removal.

Bowman wrote that “once this issue was identified, Anthem implemented an internal process which included a manual override in the billing system.”

Still, Chevalier filed a complaint with the California Department of Managed Health Care, and the state declared Anthem Blue Cross out of compliance. Additionally, after KHN started asking Anthem questions about Chevalier’s bills, two claims that had not been addressed since April were resolved in July. So far, Anthem has reimbursed Chevalier around $8,000.

Some procedures that trans patients receive can also be excluded from coverage because insurance companies consider them “sex-specific.” For example, a transgender man’s gynecological visit may not be covered because his insurance plan covers those visits only for people enrolled as women.

“There is always this question of: What gender should you tell the insurance company?” said Dr. Nick Gorton, an emergency medicine physician in Davis, California. Gorton, who is trans, recommends his patients with insurance plans that exclude trans care calculate the out-of-pocket costs that would be required for certain procedures based on whether the patient lists themselves as male or female on their insurance paperwork. For example, Gorton said, the question for a trans man becomes “what’s more expensive — paying for testosterone or paying for a Pap smear?” — since insurance likely won’t cover both.

For years, some physicians helped trans patients get coverage by finding other medical reasons for their trans-related care. Gorton said that if, for instance, a transgender man wanted a hysterectomy but his insurance didn’t cover gender-affirming care, Gorton would enter the ICD-10 , into the patient’s billing record. Pelvic pain is a legitimate reason for the surgery and is commonly accepted by insurance providers, Gorton said. But some insurance companies pushed back, and he had to find other ways to help his patients.

In 2005, California passed a that prohibits discrimination by health insurance on the basis of gender or gender identity. Now, 24 states and Washington, D.C., forbid private insurance from .

Consequently, Gorton no longer needs to use different codes for patients seeking gender-affirming care at his practice in California. But physicians in other states are still struggling.

When Dr. , an internist and pediatrician at , treats a trans kid seeking hormone therapy, he commonly uses the ICD-10 code for “medication management” as the primary reason for the patient’s visit. That’s because Indiana has no law providing insurance protections for LGBTQ+ people, and when gender dysphoria is listed as the primary reason, insurance companies have denied coverage.

“It’s frustrating,” Meininger said. In a patient’s billing record, he sometimes provides multiple diagnoses, including gender dysphoria, to increase the likelihood that a procedure will be covered. “It’s not hard usually to come up with five or seven or eight diagnoses for someone because there’s lots of vague ones out there.”

Implementing ICD-11 won’t fix all the coding problems, as insurance companies may still refuse to cover procedures related to gender incongruence even though it is listed as a sexual health condition. It also won’t change the fact that many states still allow insurance to exclude gender-affirming care. But in terms of reducing stigma, it’s a step forward, Olson-Kennedy said.

One reason the U.S. took so long to switch to ICD-10 is that the American Medical Association strongly opposed the move. It argued the new system would put an incredible burden on doctors. Physicians would have to “contend with 68,000 diagnosis codes — a five-fold increase from the approximately 13,000 diagnosis codes in use today,” the AMA . Implementing software to update providers’ coding systems would also be costly, dealing a financial blow to small medical practices, the association argued.

Unlike past coding systems, ICD-11 is fully electronic, with no physical manual of codes, and can be incorporated into a medical facility’s current coding system without requiring a new rollout, said Christian Lindmeier, a WHO spokesperson.

Whether these changes will make the adoption of the new edition easier in the U.S. is yet to be seen. For now, many trans patients in need of gender-affirming care must pay their bills out-of-pocket, fight their insurance company for coverage, or rely on the generosity of others.

“Even though I did get reimbursed eventually, the reimbursements were delayed, and it burned up a lot of my time,” Chevalier said. “Most people would have just given up.”

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The patient — a 78-year-old man — was experiencing atrial fibrillation, . But for patients like this one with chronic health conditions, a history of cardiac issues and high blood pressure, the condition can cause a stroke or heart failure.

Workers from rolled the patient, who was on a gurney, out of the hospital and into the frigid night air. AnnieGrace Haddorff, the emergency medical technician on call, helped load the patient into the ambulance and jumped into the driver’s seat. Paramedic Alec Newby got into the back and hooked the patient up to a blood pressure cuff; a pulse oximeter, which measures heart rate and blood oxygen saturation; and an electrocardiogram, which records the heart’s electrical activity.

“Your heart is obviously pissed off,” Newby told the man as the ECG confirmed the atrial fibrillation.

The ambulance pulled onto U.S. Highway 50 for the one-hour-and-15-minute drive past clusters of homes among rolling hills of sagebrush, the expansive Blue Mesa Reservoir and the gaping Black Canyon of the Gunnison, with its craggy spires.

The patient was stable enough for the long drive, which covered only a sliver of GVH Paramedics’ 4,400-square-mile service area. It is more than twice the size of Delaware and is the largest response zone for an ambulance service in all of Colorado. A typical fire or emergency medical service response area ranges from 100 to 400 square miles.

In recent years, interfacility transports or transfers, also known as IFTs, like this one have become increasingly common for GVH Paramedics, forcing the team to drive far outside its already vast zone. Before the pandemic, the number of transfers rose because the population of Gunnison County was steadily increasing, more tourists were being drawn to places like the popular Crested Butte ski resort, and GVH Paramedics had expanded its services to larger metropolitan hospitals outside Gunnison County.

But now the team is being called to move patients more frequently, and greater distances, because the hospital beds in the relatively close cities of Montrose and Grand Junction are filled with covid-19 patients. The team is regularly required to drive patients to Denver, which is around three hours and 40 minutes from Gunnison.

Officials from the ambulance service worry that they might find themselves unable to respond to an emergency because their resources, which include six ambulances but only enough staff to operate three of those vehicles, are tied up on a long-haul transfer.

What were once 2½- or three-hour trips to Montrose are now far longer excursions, “and that takes resources from this community,” said CJ Malcolm, chief of emergency services. “We were doing that pre-covid, but now the state is so impacted, it’s like a daily part of our lives.”

Before the pandemic, all the ambulances would be simultaneously out on 911 calls or IFTs fewer than 10 times a year. Now, Malcolm said, it is happening with greater frequency. In those cases, GVH Paramedics leans on the emergency response team in Crested Butte, about 28 miles from Gunnison, or the response to the patient is delayed.

In 2018, GVH Paramedics made 166 IFTs, requiring nearly 40,000 miles of travel and a total of 987 hours of ambulance operation, according to data collected by the team. Last year concluded with 260 IFTs, over 70,000 miles of travel and a total of 1,486 hours of ambulance operation. That’s a 50% increase in time on the road.

“Anytime we have one or two ambulances out on an IFT, this leaves a massive tract of land with only one ambulance to respond,” Malcolm said. “This is a moderately terrifying position to be put into when we can easily have two or three 911 calls in a row.”

In August, for example, Gunnison Valley Health hospital transferred more than 60 patients, 37 of whom were transported by GVH Paramedics. That means that at least once a day that month, a GVH Paramedics crew was taking a patient out of town, Malcolm said. And if crew members aren’t scheduled to be back in Gunnison by 1 a.m., they must spend the night in a hotel to avoid driving along treacherous mountain roads while overly tired.

GVH Paramedics’ service area covers almost all of Gunnison County, a large portion of Saguache County and sections of Montrose and Hinsdale counties. It contains mountain ranges, canyons and wide expanses of high desert. With around 6,600 full-time residents and a university, Gunnison is the largest town the team serves. The surrounding towns — including Tin Cup, Pitkin and Ohio City — are villages with a couple of hundred people or former mining towns where the artifacts from the boom times outnumber the residents.

GVH Paramedics’ 21 full-time staff members and 10 to 20 individuals who work as needed have certifications in wildland firefighting and backcountry medicine skills, including swift-water, ice and avalanche rescue. To deal with the increased demands from IFTs, they have added an extra staff member to each shift, and off-duty staffers are being called in to assist.

As the pandemic drags on, the number of IFTs will probably continue to increase. By mid-November, the number of people in the hospital with covid-19 in Colorado was , approaching the December 2020 peak of 1,847. Hospitalizations remained above 1,500 through the end of the month. As a result, 93% of the state’s acute care hospital beds and 94% of ICU beds were being used as of Nov. 30, according to data from the .

“I don’t think we see the capacity concerns easing anytime soon,” said Cara Welch, senior director of communications at the Colorado Hospital Association.

Adding to the strain are people seeking care they delayed because of the pandemic and other respiratory viruses, such as respiratory syncytial virus, circulating in the state, Welch said.

Kelly Thompson, chief of operations of CareFlight of the Rockies, an air ambulance service that operates in Colorado and other parts of the West, agreed with this assessment. “We’ve already been transporting large numbers of kids with RSV that are sick, and you have covid on top of all of this,” Thompson said. “It’s a big concern. This is the time when we have a lot of sick people.”

In early November, to manage escalating concerns about hospital capacity, Colorado hospitals and health systems — the highest level. That means covid and non-covid patients can be moved without their consent from a hospital that doesn’t have enough capacity to one with more space. Hospitals can also send sicker patients to medical centers with more specialized care.

As the GVH Paramedics crew members approached Montrose with their patient over the recent holiday weekend, Newby called the hospital to let the staff know they were arriving. They pulled up to the emergency room entrance, and Newby and Haddorff rolled the patient into a hospital room. The Montrose hospital staff took over, moving the patient from the gurney to a hospital bed as Newby updated them on the patient’s medical records.

Soon they were back in the ambulance, headed for home. “IFTs can be stressful,” said Haddorff as she maneuvered the twisty mountain road bathed in moonlight.

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Esto fue hasta que perdió su trabajo en abril de 2020 y cambiamos a un plan médico privado subsidiado en el mercado de seguros de Colorado, establecido por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Descubrimos que nuestro nuevo seguro de Anthem no cubre el Depo-Estradiol y que el gasto de bolsillo por vial sería de $125. Con nosotras, y nuestras cuatro mascotas, dependiendo en gran medida del cheque de desempleo semanal de $649 de Ky, estos gastos médicos resultaron difíciles.

Y a partir del , esos cheques de desempleo se agotaron.

“Estoy absolutamente estresada. No sé qué hacer “, dijo Ky en agosto mientras intentábamos encontrar una solución.

Debido a la transición física de Ky como mujer transgénero, su cuerpo no produce la testosterona que solía producir. Entonces, sin la medicación, esencialmente atravesaría la menopausia. Una disminución en los niveles de estrógeno también puede hacer que las mujeres transgénero pierdan las transiciones físicas que han logrado, lo que resulta en disforia de género, que es una angustia psicológica por el desajuste entre su sexo biológico y su identidad de género.

Desafortunadamente, muchas otras estadounidenses transgénero comparten la experiencia de Ky. La pandemia de covid-19 ha provocado que millones de personas pierdan su trabajo y su seguro médico privado, , quienes han reportado quedarse sin empleo en tasas más altas durante esta crisis que los que no lo son.  

En consecuencia, la inscripción aumentó en los planes de ACA y en , el programa de salud estatal-federal para personas de bajos ingresos. Sin embargo, muchas de estas pólizas no cubren por completo la atención que afirma el género, en parte debido a las políticas conservadoras y a la falta de investigación científica sobre cuán crucial es esta atención para los pacientes transgénero.

Según una encuesta de Out2Enroll, una iniciativa nacional para conectar a las personas LGBTQ con la cobertura de ACA, el 46% de los 1,386 planes de Plata del mercado encuestados cubren todo o parte del . Sin embargo, el 7% tiene exclusiones específicas para personas trans, el 14% tiene algunas exclusiones y el 33% no especifica.

“Es esta situación en la cual los planes en su mayor parte no tienen exclusiones generales, pero las personas todavía tienen dificultades para cubrir procedimientos específicos, medicamentos, etc.”, dijo Kellan Baker, director ejecutivo de Whitman- Walker Institute, una organización sin fines de lucro que se centra en la investigación, las políticas y la educación LGBTQ.

Veintitrés estados y Washington, D.C., incluyen atención de afirmación de género en sus planes de Medicaid. Pero esta cobertura. En 2019, un estimado de , un número que probablemente ha aumentado durante la pandemia.

Sin embargo, incluso en estados como California que requieren que sus programas de Medicaid cubran la atención de afirmación de género, los pacientes todavía luchan por obtener estrógeno inyectable, dijo la , internista que fundó el . Si bien el Medi-Cal, el programa de Medicaid del estado, cubre el Depo-Estradiol, los médicos deben solicitar autorizaciones de tratamiento para demostrar que sus pacientes necesitan el medicamento. Weiner dijo que rara vez se aprueban.

Estas “autorizaciones previas” son un problema en los planes de Medicaid y ACA para medicamentos que incluyen estrógeno y testosterona inyectables, que utilizan los hombres transgénero, explicó Baker.

La falta de cobertura de fácil acceso puede reflejar el hecho de que el estrógeno inyectable, que proporciona las altas dosis de la hormona necesaria para que las mujeres transgénero hagan la transición física, no es comúnmente utilizado por mujeres no trans que se someten a terapia hormonal para tratar la menopausia u otros problemas, dijo Weimer.

También puede deberse a que existen opciones más baratas, incluidas las píldoras de estrógeno diarias, pero aumentan el riesgo de coágulos de sangre. Los parches de estrógeno liberan la hormona a través de la piel, pero pueden causar reacciones cutáneas, y muchas personas luchan por absorber suficiente estrógeno, dijo Weimer. Por eso, muchos de los pacientes de Weimer usan hasta cuatro parches a la vez, pero Medi-Cal limita la cantidad de parches que los pacientes pueden recibir mensualmente.

Si bien tales brechas en los seguros han existido desde mucho antes de la pandemia, la crisis actual parece haber amplificado el tema, según Weimer.

ACA prohíbe la discriminación por motivos de raza, color, país de origen, edad, discapacidad y sexo en los programas y actividades de salud que reciben asistencia financiera federal. La administración Trump redujo significativamente el poder de esa disposición, incluyendo la eliminación de .

Sin embargo, en junio de 2020, antes de que las regulaciones de Trump pudieran entrar en vigencia, la Corte Suprema , que la discriminación laboral basada en el sexo incluye la orientación sexual y la identidad de género.

Esta decisión histórica ha servido como una herramienta crucial para abordar la discriminación LGBTQ en muchos aspectos de la vida, incluida la atención médica. Desde julio, por ejemplo, el Medicaid en después de que Swan Being, una mujer transgénero, ganara una demanda colectiva que se basó en parte en la decisión de Bostock.

La administración Biden anunció en mayo que la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos (HHS) en su aplicación de la disposición contra la discriminación de ACA. El mes siguiente, los beneficios de salud de la Oficina de Asuntos de Veteranos se ampliaron para incluir la .

Pero por ahora, la presión de luchar por sus beneficios de salud sigue recayendo en pacientes como Ky.

Tony Felts, vocero de Anthem, dijo que Depo-Estradiol no está en la lista de medicamentos cubiertos de sus planes ACA, aunque muchos de sus planes privados patrocinados por empleadores lo cubren.

Como teníamos uno de esos planes de ACA, Ky tuvo que ser persistente. Después de cuatro meses de correos electrónicos y llamadas telefónicas, y justo antes de que se agotara el dinero del desempleo, Anthem finalmente autorizó su Depo-Estradiol. Durante el próximo año, el costo de bolsillo será de $60 por vial. Todavía es caro para nosotras en este momento, pero encontraremos la manera de que funcione.

“La realidad es que las personas trans tienen más probabilidades de estar en la pobreza y no tienen el tiempo ni el conocimiento para pasar cuatro meses luchando por obtener su estradiol como yo”, dijo Ky.

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That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in Colorado’s Affordable Care Act marketplace. We discovered that our new insurance from Anthem doesn’t cover Depo-Estradiol and it would cost $125 out-of-pocket per vial. With both of us — and our four pets — depending heavily on Ky’s weekly $649 unemployment check, such medical expenses proved difficult. And , those unemployment checks ran out.

“I’m absolutely stressed. I don’t know what to do,” Ky said in August as we tried to find a solution.

Because of Ky’s physical transition as a transgender woman, her body doesn’t make the testosterone it once used to. So, without the medication, she would essentially go through menopause. A decline in estrogen levels can also cause transgender women to lose the physical transitions they’ve achieved, resulting in gender dysphoria, which is psychological distress from the mismatch between their biological sex and their gender identity.

Unfortunately, Ky’s experience is shared by many other transgender Americans. The covid-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults, who reported at higher rates . Consequently, enrollment surged in ACA plans and Medicaid, the . Yet many of those plans don’t fully cover gender-affirming care, partly because of conservative policies and lack of scientific research on how crucial this care is for transgender patients.

According to a survey by Out2Enroll, a national initiative to connect LGBTQ people with ACA coverage, 46% of the 1,386 silver marketplace plans polled cover all or some . However, 7% have trans-specific exclusions, 14% have some exclusions, and 33% don’t specify.

“It’s this whack-a-mole situation where plans for the most part do not have blanket exclusions, but where people are still having difficulty getting specific procedures, medications, etc., covered,” said Kellan Baker, executive director of the , a nonprofit that focuses on LGBTQ research, policy and education.

Twenty-three states and Washington, D.C., include gender-affirming care in their Medicaid plans. But . In 2019, an estimated , a number that has likely grown during the pandemic.

Yet even in states such as California that require their Medicaid programs to cover gender-affirming care, patients still struggle to get injectable estrogen, said Dr. , an internist who founded the . While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must request treatment authorizations to prove their patients need the drug. Weiner said those are rarely approved.

Such “prior authorizations” are an issue across Medicaid and ACA plans for medications including injectable estrogen and testosterone, which is used by transgender men, Baker said.

The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed for transgender women to physically transition, isn’t commonly used by non-trans women undergoing hormone therapy to treat menopause or other issues, Weimer said.

It also may be because cheaper options, including daily estrogen pills, exist, but these increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said. Consequently, many of Weimer’s patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get monthly.

While such insurance gaps have existed for long before the pandemic, the current crisis seems to have amplified the matter, according to Weimer.

The ACA prohibits discrimination based on race, color, national origin, age, disability and sex in health programs and activities that receive federal financial assistance. The Trump administration significantly narrowed the power of that provision, including eliminating .

However, in June 2020, before the Trump regulations could take effect, the Supreme Court ruled in , that employment discrimination based on sex includes sexual orientation and gender identity.

This landmark decision has served as a crucial tool to address LGBTQ discrimination in many aspects of life, including health care. As of July, for example, after Swan Being, a transgender woman, won a class-action lawsuit that relied in part on the Bostock decision.

The Biden administration announced in May that the U.S. Department of Health and Human Services Office for Civil Rights will in its enforcement of the ACA’s anti-discrimination provision. The next month, Veterans Affairs health benefits were expanded to include .

But for now, the pressure is still on patients like Ky to fight for their health benefits.

Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of covered drugs for its ACA plans, though many of its private employer-sponsored plans cover it.

Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls — and just before unemployment ran out — Anthem finally authorized her Depo-Estradiol. That brings her out-of-pocket cost to $60 per vial for the next year. It’s still expensive for us right now, but we’ll find a way to make it work.

“The reality is that trans people are more likely to be in poverty and don’t have the time or knowledge to spend four months fighting to get their estradiol like I did,” Ky said.

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