The Ask the Analyst series is a deep dive into the data by those most familiar with the CO APCD – the analysts themselves. We’ll hear about their experiences with recent analyses and answer any pressing questions that come up. Have a question for the CIVHC Analyst Team? Email it to email@example.com.
Analyst Name: Benjamin Hauschild, MPH, Evaluation Program Manager
Featured Project: Gender Affirmation Data Byte
Project Purpose (in one sentence, what high level question was this analysis trying to answer?):
This analysis aims to understand how access to gender-affirming care has changed in Colorado since Medicaid began covering services in 2017 and the state required gender-affirming care as an essential health benefit for commercial plans (compliance required by 2023).
- What is gender-affirming care and why is access important?
Gender-affirming care typically refers to care received by a person whose assigned sex at birth doesn’t match their gender identity. Gender-affirming care can help address gender dysphoria, or the discomfort or distress a person feels when their sex assigned at birth doesn’t match their gender identity. Care can include social, emotional, behavioral, and medical care and encompasses anything from using a person’s pronouns, to social support, to gender confirmation surgery. Gender-affirming care is common among transgender, gender diverse, and non-binary (TGDNB) individuals. Sex describes a person’s biology (their chromosomes, hormones, and anatomy) while gender describes a person's perception of themselves as a man, woman, or another gender. Gender-affirming care is routine for cisgender persons (persons whose sex assigned at birth matches their gender identity) and includes things such as addressing people by their pronouns, men who seek testosterone therapy, women who seek hormone therapy, or people who seek cosmetic surgeries. Gender-affirming care applies to everyone and provides essential support for people during a difficult time in their lives, and it’s both compassionate and necessary. For the purposes of our analysis, we focused on TGDNB youth seeking gender-affirming medical care.
- Why is the CO APCD in a unique position to conduct this analysis given Colorado insurance payment policies?
Medicaid began covering gender-affirming care in Colorado in 2017. In October 2021, Colorado became the first state to require gender-affirming care for TGDNB persons to be covered as an essential health benefit by Medicaid and private insurance plans in the state. The requirement was also approved by the Centers for Medicare & Medicaid Services (CMS) for plans covered by the Affordable Care Act and offered through the health insurance marketplace. The CO APCD is a logical source of information for this analysis as it includes all lives covered by Medicaid and the majority of lives covered by commercial insurance plans. Included in medical claims submitted to the CO APCD are a set of F-Codes, ICD codes that can identify persons who identify as TGDNB. Also included are CPT codes, or treatment codes, that can show us the numbers and types of care received by individuals.
- Were there specific considerations CIVHC needed to consider in presenting the data?There were several key factors CIVHC considered when developing the methods and presenting the data. First, some of the language in the list of ICD-10 codes isn’t very affirming and we chose to combine small categories of diagnoses into larger categories and to use gender-affirming labels to identify the data. Additionally, because our analysis is focused on youth and young adults, we chose to group the categories by youth 17 and under and 18 to 24 years of age. Additionally, due to the change in coverage requirements, we saw a large increase in the volume of gender-affirming claims in recent years and needed to be careful to not misattribute that care to an increase in the number of people needing care, but rather an increase in the number of people getting access to these essential services through their health insurance for the first time. This is an important distinction to make and provides critical context to the information to avoid misinterpretation.
- Based on the results of the analysis, what are your takeaways for how Colorado is serving people in need of gender-affirming care?
Based on data from the U.S. Census1 and the Youth Risk Behavior Survey2, we estimate that in 2021, approximately 20% of TGDNB young people in Colorado received gender-affirming care as a covered service. We think Colorado has made great strides in addressing the health care needs of TGDNB youth through policy, but there may still be unmet needs for young people in the state. People who are seeking care need to be treated in an affirming manner and provided with the support they need. Something as simple as using a person’s pronouns can make the difference between whether someone decides to seek care or not. Increasing the number of youth and young adults receiving gender-affirming care is a positive step towards CIVHC’s efforts to reduce health inequities and our ultimate mission to improve the lives of Coloradans by lowering costs, improving health, and improving quality.
- What lessons could other states learn from Colorado’s work in this areaUnfortunately, many states have recently taken an anti-transgender position to gender-affirming care. This is a missed opportunity to provide care to transgender, gender diverse, and non-binary youth. Research has consistently demonstrated that gender-affirming care reduces depression and suicidality. Colorado’s efforts to improve access to gender-affirming care should be seen as a model for other states, not a hindrance. Ultimately, compassionate, gender-affirming care means that more people are engaged with health care providers and will have better health outcomes.