Last year, Chelsea Manning—the Army private who was arrested for leaking thousands of classified documents to the website Wikileaks—made headlines again for receiving hormone therapy to change genders while in military prison. Although the military does not cover gender transition, Army officials provided hormone therapy after Manning sued to obtain treatment.
Manning’s story highlights a gap in medical coverage that likely affects other soldiers, and not just those in military prison. Estimates based on a survey of the transgender community show that the U.S. armed forces may have over 12,000 transgender personnel. Although many of these service members may need gender transition services like hormone therapy, the military health insurance program Tricare categorically excludes treatment for gender dysphoria—a condition where individuals do not identify with their physical genders.
But a new proposed rule could help close this gap. As part of a larger proposal that would expand Tricare’s mental health and substance abuse benefits, the U.S. Defense Department would remove Tricare’s categorical exclusion of gender dysphoria and provide coverage for non-surgical services like hormone replacement therapy. Surgical treatments such as sex reassignment surgery would remain uncovered.
The proposal follows an announcement last summer from Secretary of Defense Ashton Carter, who criticized the Defense Department’s current ban on individuals serving in the military who openly acknowledge their transgender status. Addressing the ban’s harmful impact on transgender personnel, Secretary Carter convened a working group tasked with lifting the restriction. The media have reported that the ban is expected to end this spring.
However, the Defense Department has stated that the recent proposed rule is not related to a decision to end the ban on service for transgender individuals.
“This rule being put up for public comment is in no way related to a decision by the secretary to allow transgender troops to serve openly,” Defense Department spokesperson Air Force Major Benjamin Sakrisson reportedly told the Military Times.
In spite of these agency remarks, military advocates still see the proposed rule as a sign that the overall ban will be lifted. Other advocacy groups praised the proposal for enabling more personnel to obtain critical health care. Sue Fulton, board chair of the LGBT military advocacy group SPARTA, reportedly deemed the proposal a “modest but positive step forward” in meeting medical standards for transgender care.
The expense of gender transition services is a concern. According to Pete Sepp, president of the citizen group National Taxpayers Union, the cost of providing this treatment may detract from coverage of other services that military members need.
“If transition-related care is deemed a necessity, then preserving other vital health services for the troops should mean finding lower-priority items to cut so service people and taxpayers are protected,” Sepp apparently remarked.
Other commenters criticized the recent proposed medical insurance rule for not going far enough. A commenter on the proposal noted the lack of coverage for gender reassignment surgery, commenting that the World Professional Association for Transgender Health identifies surgery as a medically necessary service for gender dysphoria. Advocacy groups state that among certain patients with gender dysphoria, sex reassignment surgery might be the only appropriate therapy. Patients who lack insurance coverage could have to pay up to $10,000 for gender transition surgeries.
Veterans who receive health benefits through the U.S. Department of Veterans Affairs (VA) currently get coverage for gender transition services like hormone therapy. Certain VA hospitals also offer clinics that specialize in serving transgender patients. However, like the Tricare proposal, the VA excludes surgical treatments for gender dysphoria.
William Padula, an assistant professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, has pointed out that surgical treatment like sex reassignment surgery can lower overall health care expenses by preventing other issues, like depression, that frequently affect patients who cannot change genders due to financial barriers.
The Tricare proposal aims to align benefits with provisions in the Affordable Care Act (ACA) focused on transgender patients. In a yet-be-finalized proposed rule issued by the agency implementing the ACA, the Department of Health and Human Services (HHS), insurers which receive federal funding could not categorically deny coverage for gender dysphoria treatment. Unlike the Tricare proposed rule, the HHS proposal would not specifically exclude surgical services.
In 2014, the Obama Administration also removed a ban on sex reassignment surgery under Medicare, which means this treatment is now covered for transgender beneficiaries who demonstrate surgery is medically necessary. Similar to what the Tricare proposal would cover, Medicare already covered non-surgical treatments such as hormone therapy. If the Defense Department proposed rule is adopted without change, this will mean that transgender service members will receive less coverage for care than Medicare patients.
In addition to addressing gender transition services, the proposed Tricare rule would end yearly and lifetime limits on substance abuse treatment, as well as offer coverage for new services that address opioid addiction.
The proposed rule would also get rid of caps on the number of days Tricare recipients can stay in inpatient mental health facilities and the number of covered psychotherapy and family therapy sessions. In addition, the proposal would reduce co-pays for individual and group outpatient mental health visits.
Public comments on the proposed Tricare rule are due April 1, 2016.