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Navigating Barriers: Regional Disparities and Policy Impacts on U.S. Insurance Coverage of Gender-Affirming Surgeries
Morvarid Mehdizadeh
*1, Jian Li
2, Tricia M. Raquepo
1, Mohammed Yamin
1, Micaela J. Tobin
1, Agustin N. Posso
1, Lacey Foster
1, Samuel J. Lin
1, Bernard T. Lee
1, Ryan P. Cauley
11Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA; 2SUNY Upstate Medical University, Syracuse, NY
Background:Despite the medical necessity of gender-affirming surgeries (GAS), insurance coverage remains limited. This study reviews the insurance landscape for GAS in the U.S. to inform policy reform.
Methods:Policies from the top three insurers in each state were analyzed. Coverage data were compared across U.S. Census regions and assessed for concordance with WPATH SOC v8. The impact of GAS fellowship availability on regional coverage was evaluated. Policy information accessibility was measured on a 7-point Likert scale. Legislative favorability for LGBTQ+ policies was assessed using validated Movement Advancement Project scores. Statistical analyses included ANOVA, Tukey's Honest test, Poisson, and logistic regression using R 4.4.1.
Results:147 policies were analyzed, representing 76.7% of the U.S. insurance market. Overall GAS coverage rate was 67.7%. Fertility cryopreservation, facial feminization, and reversal surgery procedures were significantly less covered compared to all other gender-affirming categories. Positive predictors of gender-affirming surgery coverage were the presence of a gender-affirming surgery fellowship in the state (p<0.001) as well as fair (p=0.041) and medium (p=0.004) rated state legislative favorability compared to negatively rated states. Insurance information was easier to access in the West, Northeast and Midwest regions compared to the South (p<0.001). Overall legislative favorability was a positive predictor of ease of information access with high (p<0.001), medium (p<0.001) and low (p<0.001) scores compared to negatively rated policy scores. 61.9% of insurance policy criteria were WPATH concordant with 72.0% of facial reconstructive surgeries, 58.6% of bottom surgeries, and 56.9% of top surgery insurance criteria being WPATH concordant.
Conclusion:Our findings highlight regional disparities driven by politics rather than medical necessity, non-concordance with international guidelines, and systematic information access barriers. Fellowships may enhance local healthcare infrastructure and reflect policy support.
Figure 1. Gender Affirming Care Procedural Coverage
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