Insurance-Based Discrimination As Barriers to Transgender Healthcare: Differences in Experience By Insurance Type

Background/Purpose: Transgender and non-binary people continue to face barriers in accessing gender-specific healthcare. This includes insurance-based discrimination and coverage denials. Researchers and practitioners have described variations in transgender-related insurance policy and programs that may contribute to discriminatory experiences. However, when comparing insurance types, studies have under considered variation in the type of discrimination experienced. To fill this gap, this study asks the following research question: how does type of insurance coverage affect the likelihood of transgender/non-binary people experiencing different forms of insurance-based discrimination? Investigating this question advances our understanding of how insurance coverage may contribute to the multiple discriminatory barriers transgender people may face in accessing healthcare.

Methods: This study uses cross-sectional data from the 2015 United States Transgender Survey, the largest sample of transgender and non-binary people in the United States to date. Using recommended survey weights, the final weighted sample size (N=9971) includes those who have insurance coverage and reported attempting to access at least one of seven forms of care through insurance. Care-related discriminatory experiences include insurance denials for transition-related hormone therapy (1), transition-related surgery (2), other gender-specific healthcare (3), and routine healthcare (4), insurance either not covering certain transition-related procedures (5) or having no in-network surgery providers (6), and insurance not changing patient records to current name or gender (7). Approximately 56% of all transgender/non-binary people in this study experienced a form of insurance-based discrimination.

Multivariate logistic regression was conducted to analyze the odds of experiencing any form of insurance-based discrimination by insurance type, including private insurance, Medicare, Medicaid, military-based insurance, and having multiple types of insurance coverage. Additionally, logistic sub-analysis was conducted to compare each of the seven forms of discrimination by insurance type. The strength of association was estimated by calculating odds ratios (OR) with 95% confidence intervals (CI). Prevalence of each form of discrimination by insurance type was ascertained through bivariate cross-tabulation.

Results: Regression results reveal that when collapsing all forms of discrimination together, there are no significant differences among insurance types for greater or lesser odds of experiencing discrimination. However, when evaluating each of the seven forms of discrimination separately, significant differences are revealed. Those covered by Medicaid (OR: 1.79, CI: 1.23 – 2.59) and Medicare (OR: 2.77, CI: 1.55 – 4.95) have greater odds of having no in-network surgery providers, in comparison to those with private insurance. While those covered by Medicaid have greater odds of experiencing transition-related hormone denials (OR: 1.33, CI: 1.07 – 1.66), those with military-based insurance have only half the odds (OR: .55, CI: .35 – .88). These and other sub-analyses demonstrate that insurance type is a significant predicator of experiencing different discriminatory barriers to necessary care.

Conclusions/Implications: Findings indicate that researchers and practitioners must consider the link between type of insurance coverage and experiences with different forms of transgender-related healthcare discrimination. This provides continuing support for broad non-discrimination policy efforts, but also directs our attention to targeted insurance policy interventions by form of discrimination, which can promote equitable access for transgender/non-binary people across all healthcare needs.