LAUSR

Historically, many healthcare plans excluded coverage for transgender patients resulting in denial of services for both transition and non-transition care for transgender and gender nonconforming individuals [1]. More recently, in part due to federal regulatory actions around implementation of the Affordable Care Act (ACA), third party payers have expanded access to treatment for transgender patients [2]. While this shift improves the environment for transgender patients to access medical care, transgender people continue to experience economic hardships and may lack access to adequate insurance coverage and/or the ability to pay out-of-pocket costs associated with services not covered by health plans. According to the 2015U.S. Transgender Survey, the experiences of transgender people living in the United States, 29% of transgender people live in poverty, while 15% are unemployed, compared to 5% of the total U.S. population [3]. These numbers are consistently higher for transgender people of color. Even when patients have access to health insurance, additional barriers to care may prevent utilization of services: unstable housing can unexpectedly move patients away from providers with whom they have trusted relationships; lack of transportation may prohibit patients from getting to scheduled appointments; and basic living costs (i.e. food and housing) often take precedence over the additional costs of routine check-ups or obtaining medications [4]. Furthermore, additional research shows that these factors are not necessarily the most pertinent. According to a manuscript published in the April 2016 edition of Current Opinion in Endocrinology, Diabetes and Obesity, investigators cite the most significant barrier to care is finding providers with expertise in transgender health, particularly the administration of hormone therapy [5]. Most medical training programs are still not teaching about transgender healthcare, and trainees often do not get exposure to a significant cohort of transgender patients [6]. Still, if patients are able to access care from a culturally competent provider, they may not necessarily feel welcome or safe. Studies dating back to 2010 consistently demonstrate that transgender people disproportionately experience discrimination in the healthcare setting [7–11]. Prior to a visit with a provider, transgender people may face stigma or negative behavior from other office staff members [12]. Additionally, most electronic health records do not accurately capture gender identity data, and patients are likely to be misgendered or addressed inappropriately upon arrival [13]. For people living with gender dysphoria, these encounters can exacerbate anxiety, depression, or other mental health concerns. Also, when gender identity is not congruent with a patient’s health record, coding for genderspecific procedures like hysterectomies often delay approval from third party payers, thereby offsetting some of the progress cited above. Given the ongoing barriers to care experienced by transgender patients, we sought to understand the latest trends in healthcare utilization between transgender/gender-non conforming and cisgender (i.e. not transgender) patients with access to health insurance.