Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis
Societal Implications of Health Insurance Coverage for Medically Necessary Services in th eTraUn.Ss.gender Population: A Cost-Effectiveness Analysis
William V. Padula
MS MSc 2
Jonathan D. Campbell 0
0 Center for Pharmaceutical Outcomes Research (CePOR), Department of Clinical Pharmacy, University of Colorado , Aurora, CO , USA
1 Commonwealth of Massachusetts Group Insurance Commission (GIC) , Boston, MA , USA
2 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health , Baltimore, MD , USA
BACKGROUND: Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. OBJECTIVE: To analyze the cost-effectiveness of insurance coverage for medically necessary transgenderrelated services. DESIGN: Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). PATIENTS: U.S. transgender population starting before transitional therapy. INTERVENTIONS: No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. MAIN MEASURES: Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. KEY RESULTS: Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000-22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints -HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations. CONCLUSIONS: Health insurance coverage for the U.S. transgender population is affordable and cost-effective,
transgender health; cost-effectiveness analysis; budget impact analysis; preventive care; health law; health insurance coverage; J Gen Intern Med 31(4); 394-401 DOI; 10; 1007/s11606-015-3529-6 © Society of General Internal Medicine 2015
and has a low budget impact on U.S. society.
Organizations such as the GIC should consider these results when
examining policies regarding coverage exclusions.
U.S. health insurance plans categorically deny transgender
enrollees coverage for medically necessary services such as
transition-related and preventive care.1
In 2013, the Commonwealth of Massachusetts Group
Insurance Commission (GIC), the state’s administrator of
employment-based health benefits to 420,000 subscribers,
prioritized research on whether the cost-effectiveness of
providing benefit coverage for transgender enrollees would
support the removal of exclusions of coverage for
transitionrelated services. Current evidence indicates that
transitionrelated care is medically necessary and effective for
transgender patients.2,3 Furthermore, recent changes in federal and
state laws may place health insurer accreditation status at risk
based on absence of coverage for transition-related care.4,5
Since negative health outcomes are associated with denial of
these services, it may be in payers’ financial interests to cover
transgender health benefits.2 Payers could increase net
monetary benefit and avoid noncompliance with regulations by
o ff e r i n g c o v e r a g e i n a c c o r d a n c e w i t h g u i d e l i n e
The American College of Physicians' position on the health
care of transgender persons is that all services should be
covered as they would for other beneficiaries, and that
coverage should not discriminate on the basis of gender identity.6
However, health insurance policies frequently prohibit
coverage for transgender people under a clause expressly
prohibiting coverage for transitional care, or based on carriers’
contract interpretation.7 Transgender exclusions result in
denial of coverage when subscriber gender marker and
physiology are incongruent.8
In 2014, the U.S. Department of Health and Human
Services lifted a 33-year ban on coverage of transitional care for
Centers for Medicare and Medicaid Services (CMS)
beneficiaries, citing that existing literature demonstrates the efficacy,
safety, and effectiveness of “sex reassignment surgery” and
that “exclusions of coverage are not reasonable.”4,5 This
stance stemmed from the U.S. Department of Justice’s
interpretation of Title VII of the Civil Rights Act that sex
discrimination prohibitions extend to health benefits of transgender
people.9 This federal decision could influence how public and
commercial payers define medically necessary services.
The most effective approach to transition uses
individualized treatment plans,10 which may require hormone
replacement therapy (HRT), mastectomy, phalloplasty, vaginoplasty,
psychotherapy, or other services.8 The prevalence of sex
reassignment surgery is 1:100,000 population, or approximately
3000–9000 in the U.S.4,8 In 2001, 866 male-to-female (MTF)
primary surgeries (bottom surgery) and 336 female-to-male
(FTM) primary surgeries (top surgery) were documented in
the U.S., and the prevalence has likely increased since then,
despite considerable under-reporting.4,8,11 These procedures
are costly to uninsured patients. In addition, many costs for
gender-specific preventive care (i.e., prostate screening,
mammograms) are not covered by insurance if a patient legally
changes their sex on their birth certificate.11,12 According to
Gorton et al., providing insurance coverage would appear
cost-effective,2 whereas negative outcomes associated with
denial of coverage could be costly to payers because of
increased morbidity.13 For instance, studies by Lundstrom and
by Kuiper and Cohen-Kettenis estimated that suicidality in
transmen dropped from 20 % to 1 % after treatment.14,15 No
studies, however, have measured the economic benefit of
health insurance coverage to transgender enrollees for
medically necessary and preventive services.
Our objective was to analyze the cost-effectiveness of
health insurance coverage for medically necessary and
preventive services compared to no coverage in the U.S. adult
transgender population. This study was designed from a U.S.
societal perspective and evaluated outcomes over 5- and
10year periods.16 We hypothesized that provider coverage is
Using a Markov model, we compared the cost-effectiveness of
health insurance for provider coverage (i.e., access to primary,
secondary, and tertiary services provided by a physician and/or
advanced practitioner) of medically necessary services in the
U.S. adult transgender population.17,18 Model parameters
were extracted from the National Transgender Discrimination
Survey (NTDS) of adults,1 and provider costs for
transitionrelated care were extracted from the Healthcare Bluebook.19
Costs were adjusted to 2013 U.S. dollar values and discounted
at 3 % along with utilities, and analyzed over 5 and 10 years.16
The analysis was conducted from a U.S. societal
perspective. Effectiveness was measured as quality-adjusted life years
(QALYs) derived from EuroQol Group EQ-5D index scores.20
Patient costs in the provider coverage arm were considered
along with probabilities for negative outcomes and any
associated costs for psychiatric rehabilitation. Patients in the
provider coverage arm were assumed to receive individualized
transition therapy.7 With no health benefit, patients were
assumed to have lower upfront costs, but higher risks for
negative outcomes, long-term costs, and lower life expectancy.
The Markov model (Fig. 1) was built using TreeAge (TreeAge
Software, Inc., Williamstown, MA, USA; 2009). With
provider coverage, 100 % of patients were modeled to have
authorized transitional therapy care in accordance with the World
Professional Association for Transgender Health (WPATH)
standards of care.3
Patients could experience a continuous progression of
outcomes in escalating stages over 1-year cycles for up to 10
years. Patients in escalated states required costly rehabilitation
to cycle through job loss/depression in order to return to a
preferable baseline state. Patients who cycled into escalated
states had increased risk of drug abuse, suicidality, and HIV.21
The risk of death included all-cause mortality22 and specific
mortality rates from suicide and drug overdose.23–25
Following transitional therapy, the model included costs for provider
coverage to reduce negative outcomes.
No Health Benefit
The structure of the no health benefit arm accounted for denial
of coverage to transgender patients for medically necessary
and preventive care, as well as adverse implications. Patients
began either at baseline or a job loss/depression state
according to the unemployment rate associated with anti-transgender
bias.1 Patients at baseline and in the job loss/depression state
were modeled as having high rates of escalating issues,
including death.1 Alternatively, patients at baseline accrued no
Patients with health insurance with provider coverage could
navigate through transitional therapy or denial. Patients denied
coverage following a mental health evaluation transitioned to
baseline or escalated states. This sub-tree accounted for
variations in policy and practice, including barriers raised through
insurance claims and coding processes. For example, if a
female-to-male (FTM) patient changed his legal gender
marker and then submitted billing for a Pap smear, coverage was
modeled as denied based on his gender marker despite the
provider’s adherence to WPATH guidelines.
Provider coverage was modeled as having higher
costs and improved quality of life. The model also
incorporated probabilities for negative health outcomes.
Most patients were assumed to receive a full range of
services indicated by WPATH, including reconstructive
The model included several assumptions. First, provider
coverage paid for the following procedural
combinations: surgery, HRT, surgery and HRT, discontinued
transition, and costs associated with baseline prevalence
of job loss/depression. Second, costs for provider
coverage were equivalent to reimbursed rates for procedural
diagnosis-related groups (DRGs). Third, transitional
therapy would maintain its baseline utility.
Data were collected from a systematic review of over 30
randomized controlled trials, observational data, and
case series detailing types of gender-confirming care,
whether transphobic-related events triggered negative
outcomes, and the existence of a defined outcome for
each related state. Many probabilities were from the
NTDS (Table 1).1
Transition costs were gathered from the GIC public record and
the literature (Table 2).11 Existing DRGs weighted by
procedural prevalence were used for initial and incremental costs of
services. Thus, costs were reflective of the most common
procedures (e.g. mastectomy) compared to rare procedures
(e.g. phalloplasty).11,17 There were no costs attributed to
baseline state or death. Depression, suicidality, and drug abuse
states resulted in rehabilitative costs.26–28 The U.S. cost of
illness for HIV was extracted from Walensky et al.29
Cost of provider coverage was dependent on
combinations of surgery and HRT. HRT was a fixed cost. The MTF
group represented combinations of penectomy, breast
augmentation, labiaplasty, and vaginoplasty. The FTM
represented combinations of mastectomy, hysterectomy,
abdominoplasty, and genital augmentation. Under provider
coverage, there was an annual cost of $2175 associated with
medically necessary services and preventive care.
Other treatment costs were based on DRGs. Escalated
states following baseline were based on employment
status. The NTDS found that 78 % of respondents who
successfully transitioned reported improved job
performance.1 Conversely, respondents who experienced job
loss were 70 % more likely to abuse substances than
employed respondents. HIV rates among the transgender
population were 400 % higher than in the general
population, and doubled with unemployment.
QALYs were extracted from U.S.-based sources (Table 3).
Baseline utility was taken as the U.S. average according to
Sullivan et al.20 This index also provided utilities for
depression (ICD-9 311) and suicidality (assumed as ICD-9 296).
Utility for HIV was referenced from Wu et al., and Coffin
et al. provided utility data for drug abuse.30,31 Surgery had a
disutility.32 Benefit coverage for transition and successful
endpoints were weighted as 0.867 QALYs, given primary
preferences for these outcomes aligned with the U.S.
Univariate and multivariate sensitivity analyses were used to
test model uncertainty. These sensitivity analyses were
performed by varying all base case estimates by reported
distributions (e.g., confidence intervals, standard deviations) or by
varying estimates ±15 % of the mean when distributions were
In one particular univariate analysis, the probability of
patients starting in job loss/depression ranged from 0–
29.9 % in the provider coverage arm, since the model assumed
some baseline prevalence of depression or unemployment not
negated by transition therapy, leading to downstream
A Bayesian multivariate probabilistic sensitivity analysis
applied distributions for each variable to characterize
uncertainty on all parameters simultaneously using 10,000 Monte
Carlo simulations. Beta distributions were used for
probabilities and utilities (i.e., values of 0.0–1.0), and gamma
distributions were used for costs (i.e., positive values).
Budget Impact Analysis
The budget impact of transgender coverage was measured
relative to the total U.S. population, thereby gauging equity
of absorbing costs of coverage in a small population.33 Budget
impact was calculated on a per-member-per-month basis for
an approximate 2014 U.S. population of 320 million (U.S.
Census Bureau, 2014). The calculation assumed that
following implementation of blanket provider coverage, there would
be an influx of about 30,000 transgender persons seeking
transitional care in the first 5 years (i.e., 6000/year taken as
the midpoint of 3000–9000 procedures per year according to
FTM female-to-male transition, HRT hormone replacement therapy, MTF male-to-female transition
Walsham).32 The additional cost would be the difference in
cost of benefit coverage from the model.
Expected Cost and Effectiveness
Provider coverage resulted in higher cost and greater
effectiveness, and was cost-effective relative to no health benefits at
5 and 10 years from a willingness-to-pay (WTP) threshold of
$100,000/QALY (Table 4). These results were driven by the
cohort without health benefits, which had less favorable
outcomes, including depression, HIV, and death. The 5-year
incremental cost effectiveness ratio (ICER) was greater than
that at 10 years, since upfront costs for transitional therapy
were not yet offset by costly long-term endpoints of excluded
coverage (e.g., HIV, drug abuse).
The 5-year budget impact analysis determined a cost of
$0.016 per member per month, meaning that if U.S. society
*The benefit of having transitional therapy is no disutility from baseline
assumed the role of paying an additional $10,614 for each
person seeking benefit coverage, the U.S. population could
absorb these costs for just cents per month.
Sensitivity and Threshold Analyses
Variations in expected values of all cost, probability, and utility
estimates did not change expected results. Univariate
sensitivity analyses indicated that the model was most sensitive to (
probability of suicidal death, (
) probability of drug abuse, and
) utilities of baseline, depression, and drug abuse. However,
univariate and two- and three-way sensitivity analyses did not
The results did not change in sensitivity analysis of patients
with provider coverage starting at a baseline with job loss or
depression. The maximum probability of 29.9 % job
loss/depression produced a 10-year ICER of only $20,942/
The probabilistic sensitivity analysis showed that provider
coverage was cost-effective compared to no health benefit in
8477 of 10,000 Monte Carlo simulations at a mean ICER of
$8655/QALY (median ICER of $8593/QALY). In 389 of these
simulations, provider coverage dominated the alternative (Fig. 2).
These findings suggest that the removal of transgender
exclusions is affordable and efficient with respect to the U.S.
population. Provider coverage is a cost-effective policy at a
willingness-to-pay threshold of $100,000/QALY. The ICER of
provider coverage for medically necessary services and
preventive care at 10 years is about $9300/QALY, which suggests
that this policy would be comparatively efficient on a
perpatient basis. Even at 5 years, this type of program still holds
good value. These findings appear robust to model uncertainty
according to sensitivity analyses. In addition, the results of the
budget impact analysis imply that this policy is affordable,
with a cost of only about $0.016 per member per month.
access to necessary care, such as those with rare diseases who
have access to necessary health technology as a result of the
Orphan Drug Act of 1983.34 For instance, cystic fibrosis (CF)
affects a population of only 30,000 individuals in the U.S., but
has evolved into a successfully treatable chronic disease with
the availability of new pharmaceuticals.35 While the cost of
ivacaftor for CF ($300,000/year) is neither affordable nor
efficient (ICER>$ 1million/QALY), this act makes it available
to CF patients.36 By the absorption of the cost of ivacaftor
across the U.S. population for people who are uninsured or
have annual incomes less than $150,000, the budget impact is
only about $0.05 per member per month.37
While justice, legality, and a desire to avoid discrimination
should drive decisions about benefit coverage, this case for the
transgender population also appears economically attractive.
The budget impact analysis calculates the expected value of
costs for a state with an average population of 700 instances of
transition therapy each year. Thus, if state governments require
that payers offer coverage, insurance companies need to
account for approximately $7.5 million per state. While
costeffective on a societal level, there is some upfront investment
required of payers. A return-on-investment (ROI) calculation
for this figure shows that it would take a payer approximately
63 years to break even on an investment in this type of benefit
However, legal and administrative barriers can hinder the
implementation of new policy informed by these results. First,
commercial payers are accustomed to negotiating contracts
and benefit packages in ways that may resist change. It may
be difficult to instantaneously adopt changes in provider
coverage when exclusions are enforced by a third party or if state
law defines health services to exclude transgender benefits.38
Fortunately, transgender exclusions were recently removed by
states, commercial payers, and CMS.4,7
According to the Human Rights Commission, 57 of the
approximately 200 major employers offering at least one
transgender-inclusive health care coverage plan were law firms,
possibly reflecting the growing legal consensus that transgender
exclusions are discriminatory in practice.7,39 At least 17 major
insurance carriers administer or provide coverage for at least
one employer or student plan offering transgender benefits
(e.g., Aetna, Cigna, Harvard Pilgrim, United Healthcare, and
Blue Cross Blue Shield Massachusetts).40 Additionally,
numerous public employers offer provider coverage (e.g., University
of California, University of Michigan, City of Minneapolis,
City of New York, and City of San Francisco).15,40 However,
most U.S. health insurance policies still contain transgender
exclusions, even though treatment of gender identity disorder is
neither cosmetic nor experimental.40,41
This study has several limitations. First, data were lacking
on whether transition-related therapy completely prevents
negative endpoints such as depression/suicidality, or whether
a baseline prevalence still exists. Second, some data in this
analysis were representative not of the transgender population,
but of the general population. Third, no empirical evidence
exists on the time-dependency of escalated issues, so expert
opinion guided transition probabilities. Fourth, no true health
utilities were available for outcomes triggered by
antitransgender bias.11 Fifth, some costs were derived from an
ad hoc survey of provider affiliates to the GIC. Although these
results should be widely applicable to most institutions, some
insurance carriers have third-party payers or self-payers that
could change the relevance of these results. Sixth, while
depression and job loss are grouped together in the model,
there may be some element of exclusivity in these two states
that cannot be well-discerned by health utility. Seventh, HIV
and drug abuse represent two of many possible negative
outcomes; the choice to highlight these in the model was based
on reported prevalence in the NTDS.
Finally, this study did not include children or adolescents,
and focused on an adult-only population, based on the age of
respondents in the NTDS. According to de Vries et al., young
adults experience alleviation of gender dysphoria and
improvement in psychological functioning following gender
reassignment.42 Given this promise, the field could benefit from
additional outcomes research among youth.
Another challenge of this study involves the premise
that outcomes research is able to justify transgender
benefit coverage. QALYs in this study come from
societal preferences for chronic conditions. People are not
asked to consider a state of being for a transgender
person who is depressed or HIV-positive, for example,
nor are transgender individuals represented. According
to Lyons et al., there is a stigma attached to the
inclusion of transgender-stratified preferences and outcomes
in trials and observation,43 which speaks to the broader
issue of gaining consensus within U.S. society in
accepting that unique services covered by transgender
benefits are as necessary as care for people not seeking
By removing transgender exclusions, society could
change the trajectory of health for all transgender
persons. It is worth considering that other costly surgeries
(e.g., breast reduction;, spinal fusion for chronic back
pain), procedures (e.g., in vitro fertilization), and health
technologies (e.g., drugs such as sildenafil citrate for
erectile dysfunction) that consensus dictates as not
medically necessary are still covered by payers. Overall,
payers may provide the motivation for progress in a
field when there is the potential of reimbursement for
improved performance. This concept could be likened to
poor outcomes of phalloplasty in MTF transitions:
surgeons might invest in trials that improve outcomes of
these complicated procedures if they knew they would
be reimbursed.44 A law protecting transgender benefit
coverage is not only medically necessary, but is morally
Ultimately, removing a clause expressly prohibiting
coverage for medically necessary care in the transgender population
is economical at a U.S. societal level. State laws that define
“health services,” thereby dictating benefit exclusions, should
be amended to reflect contemporary medical evidence.4,38,45
Affiliated contracting agencies and bodies should remove their
corresponding exclusions given that provider coverage is
affordable, efficient, and equitable.
ACKNOWLEDGMENTS: The authors wish to thank Dolores Mitchell
at the Commonwealth of Massachusetts Group Insurance
William Padula’s time for this study was supported in part by an
AHRQ F32 National Research Service Award (1 F32 HS023710-01)
as well as an unrestricted University of Chicago Medicine Small Grant
in Diversity Research. Shiona Heru was supported by a merit
fellowship from Western New England University School of Law in
affiliation with the Gender and Sexuality Center.
This study was presented as a poster at the Annual Meeting of the
Society of Medical Decision Making in Miami, Florida, in October
Compliance with Ethical Standards
Conflict of Interest: The Authors have no conflicts of interest to
declare. Authorship of this manuscript follows ICMJE guidelines; each
author is associated with conceptualization, writing, final approval,
and accountability for the work.
Corresponding Author: William V. Padula, PhD MS MSc;
Department of Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA
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