Association Between California’s State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery

• Published in: JAMA : the journal of the American Medical Association 2023-03, Vol.329 (10), p.819-826
• Main Authors: Schoenbrunner, Anna, Beckmeyer, Annamarie, Kunnath, Nicholas, Ibrahim, Andrew, Pawlik, Timothy M, Venkataramani, Atheendar, Kuzon, William Michael, Diaz, Adrian
• Format: Article
• Language: English
• Subjects: Adult; Arizona - epidemiology; California - epidemiology; Chest; Discrimination; Epidemiology; Female; Gender; Gender aspects; Gender Identity; Gender reassignment surgery; Gender-affirming care; Government programs; Humans; Implementation; Insurance; Insurance Coverage - economics; Insurance Coverage - legislation & jurisprudence; Insurance Coverage - statistics & numerical data; Insurance policies; Insurance, Health - economics; Insurance, Health - legislation & jurisprudence; Insurance, Health - statistics & numerical data; Legislation; Male; Medicaid; Medicaid - economics; Medicaid - legislation & jurisprudence; Medicaid - statistics & numerical data; Middle Aged; Original Investigation; Patients; Policies; Population studies; Residents; Sex Reassignment Surgery - economics; Sex Reassignment Surgery - legislation & jurisprudence; Sex Reassignment Surgery - statistics & numerical data; Sexual and Gender Minorities - legislation & jurisprudence; Sexual and Gender Minorities - statistics & numerical data; State insurance; Statistical analysis; Surgery; Transgender persons; United States - epidemiology; Utilization; Washington - epidemiology; Young Adult
• ISSN: 0098-7484; 1538-3598; 1538-3598
• DOI: 10.1001/jama.2023.0878

IMPORTANCE: Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. OBJECTIVE: To investigate the association between California’s 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient’s sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. DESIGN, SETTING, AND PARTICIPANTS: Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California—January 1, 2014. The date of last follow-up was December 31, 2019. EXPOSURES: California’s Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. MAIN OUTCOMES AND MEASURES: Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. RESULTS: A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions—2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P