Critics say basics should be covered first before gender reassignment

PORTLAND, Ore. -- Oregon will soon join a handful of states that will begin offering transition-related care to transgender people as part of the state's Medicaid program. Advocates are calling it a historic decision but some argue Medicaid isn't even covering the basics, like vision care.

The Health Evidence Review Commission (HERC) voted Thursday to add gender dysphoria to the list of covered conditions under the Oregon Health Plan (OHP), the state's version of Medicaid. Gender dysphoria is a condition in which people do not feel that their gender identity conforms to their birth gender. It was formerly known as gender identity disorder.

"HERC needed to evaluate the emerging research that has developed since they last looked at this topic in 1999 and review current major international treatment guidelines to ensure that Oregonians who receive health coverage through the Oregon Health Plan receive the most appropriate care," according to a Q and A fact sheet sent to the On Your Side Investigators Friday.

The review commission, a 13-member board tasked with defining the state's coverage priorities, approved coverage for cross-sex hormone therapy and gender reassignment surgery.

The commission estimated that the new coverage will impact roughly 175 Medicaid patients each year, costing an estimated $150,000, which is a fraction of OHP's total budget.

"I'm ecstatic! These procedures, these prescriptions are now only empowering but they are freeing," said Nash Jones, the community education coordinator at the Q Center in Portland. The Q Center fosters connection within metropolitan Portland's Lesbian Gay Bisexual Transgender Questioning (LGBTQ) community.

Jones continued, "As somebody who works with folks on the ground, I see these stories, I see folks who are struggling to survive, who are struggling to pick themselves up and to live thriving, authentic lives and it's because they have not had the resources to access care."

Jones said he knows personally how hard it's been to reach this point, what's being hailed as a historic decision.

"As a trans person, I've had to access this care through fundraising and relying on my own personal resources, and the fact that this is medically necessary care should be accessible through health insurance," Jones said.

But the decision caused other Oregonians to question, what they described as, gaps in coverage in the Oregon Health Plan.

"I think the priorities are just messed up," said Lynn Kadoi, a Portland resident and Medicaid recipient who's frustrated that OHP doesn't provide some vision care like eye exams and glasses. "I was angry. I was really, really angry."

Kadoi said she tried to get an eye exam last week - she needs reading glasses or possibly bifocals - but learned the exam wasn't covered under OHP. Out of pocket, she said the exam would cost $400 and said her prescription could range between $80 and $200.

"An eye exam? People can't drive, they can't do anything if they don't have the proper glasses," Kadoi said. "I'm not trying to put anybody down but I think (Oregonians) should have eye exams. I think that's vital for people's quality of life. They have the right to live the life they want to, they have a right to health care but we should have the right too."

The On Your Side Investigators looked into OHP's vision care plan and found it is limited to certain people. OHP only covers services to correct vision for pregnant women and children under age 21. It also only covers glasses for pregnant women and adults who have a qualifying medical condition such as aphakia (an absence of the lens of the eye) or keratoconus (an eye disease that affects the structure of the cornea), or after cataract surgery.

Kadoi wasn't convinced gender reassignment was a matter of life and death, but transgender advocates argue that's one of the biggest reasons for ensuring equal health coverage. Advocates insist transition-care for transgender people reduces depression and suicide rates.

State officials told the On Your Side Investigators that what makes gender dysphoria a "must cover" is what happens if the patients aren't helped. They run the risk of suicide and have a high prevalence of mental illness and that usually ends up costing more to treat than the $150,000 a year to pay for gender dysphoria cases.

State representatives also said cost is a factor. They said it would cost $22 million to provide basic eye care to all Oregonians. However, the representatives said decisions are more largely based on a ranking system used by HERC, which is designed to provide services to the most vulnerable groups first.

"To know that they have access to these procedures now, to these prescriptions, it's going to change their lives," Nash said.

Oregon joins California, Vermont and Washington, D.C., in covering gender dysphoria treatments under Medicaid.

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