Abstract Title: Association Between Utilization of Gender-Affirming Care and Insurance Payer, State, and State Policy

Background: Gender-affirming surgery/hormone therapy (GAS/GAHT) play an essential role in improving quality of life for many transgender and gender-diverse (TGD) individuals. Despite increased demand for GAS/GAHT, TGD individuals face many obstacles to care. We investigated the association between utilization rates of GAS/GAHT and insurance payer, state, and state-level nondiscrimination policies, which prohibit health plans from precluding care based on gender identity or expression. With the disparate legislative climate, it is imperative for stakeholders to understand how these factors influence national utilization rates of GAS/GAHT.

Methods: We retrospectively analyzed a cohort of TGD individuals of all ages to characterize GAS/GAHT utilization between 2010-2020 using the PearlDiver-Mariner Database, which contains all-payer claims for 151 million patients in all 50 states and DC. We used binary logistic regressions to evaluate associations between insurance payers (private, Medicaid, Medicare) and GAS/GAHT, while testing for effect modification by individual states. Furthermore, we designed a difference-in-differences analysis to compare GAS/GAHT utilization among those who did and did not live in states that passed policies prohibiting healthcare access discrimination by insurance payers.

Results: 77,366 individuals were included in the study. The distribution of insurance payers was as follows: 77% private, 16% Medicaid, 7% Medicare. GAS/GAHT utilization was highest among the privately insured and lowest among the Medicare subgroups. Individuals covered by Medicaid (OR=0.78,95% CI=0.73-0.83) or Medicare (OR=0.69,95% CI=0.63-0.75) were less likely to undergo GAS compared to the privately insured. Similar differences in GAHT utilization were observed. Effect modification by state was evident in both outcomes. For example, differences in GAHT utilization rates by insurance payers were smaller among those living in Illinois (38% private, 37% Medicaid, 33% Medicare) compared to Idaho (35% private, 15% Medicaid, 23% Medicare). Quasi-experimental analysis suggested that nondiscrimination policies were associated with increased national all-payer treatment utilization, especially GAS, which more than doubled after implementation.

Conclusion: Our study highlights three main findings: 1) Across all states, individuals covered by Medicaid/Medicare received GAS/GAHT less often compared to the privately insured, 2) Some individual states had minimal insurance payer discrepancies in GAS/GAHT utilization, and 3) While these insurance payer differences in utilization remain at the national level, individuals living in states that implemented nondiscrimination policies experienced an increase in GAS/GAHT post-implementation. Overall, nondiscrimination policies implemented in 21 states and DC increased GAS/GAHT utilization, but challenges at the insurance payer and individual state level continue to threaten TGD individuals’ healthcare and lives.