The Wall Street Journal Reports on Legal Aid’s Successful Fight for Transgender Youth Health Care and Shows the Human Impact of Coverage Expansion

Following years of advocacy by The Legal Aid Society, Willkie Farr & Gallagher LLP and the Sylvia Rivera Law Project, New York State’s Medicaid program will begin to pay for the health care that low-income transgender youths need and deserve, effective today.

The Wall Street Journal reported on the coverage expansion for gender-transition care, as well as Legal Aid’s underlying 2014 class action lawsuit against the New York State Department of Health. Among his rulings in Cruz v. Zucker, 14-cv-4456, Southern District Judge Jed Rakoff held that transgender youth did not need to wait for any state regulatory process to unfold before receiving needed health care. The judge’s October ruling came after the state Department of Health proposed rules permitting Medicaid coverage for hormone therapy and other procedures to treat gender dysphoria for individuals younger than age 18 – an admission the procedures were necessary.

In a separate article, the Journal put a human face on the litigation and the broader issue of transgender youth health care access. The article told the story of 15-year-old Mia Ballard, one plaintiff in the Cruz litigation, and described Mia’s childhood struggles as a boy named John. At one point, the article described a note where the youth wrote, “Mom, I love you and everything you’ve done for me. I don’t want you to hate me after this, but I’ve always felt like I’ve been a girl.” Mia’s mother and grandmother have supported and defended her.

The article described the psychological issues for teenagers questioning their gender, as well as the steep financial costs of transition care. When Medicaid refused to pay for Mia’s prescribed medication to stall puberty, she received the medication, costing about $25,000 a year, under a pharmaceutical company’s “compassionate use” program.

Speaking of the Medicaid expansion, Mia’s doctor – who also treats about six other pediatric transgender patients with Medicaid coverage – told the Journal “it will make a real difference.” Meanwhile, Mia’s mother expressed relief with the transition, saying she “gained a girl out of it.”

The Wall Street Journal
New York Expands Transgender Health Care
By Corinne Ramey
December 6, 2016

Medicaid in New York will begin covering gender-transition care for youths under a state regulation that goes into effect Wednesday, health department officials said.

The court-ordered expansion of coverage is the latest in a series of changes instituted by the Department of Health in the past two years related to transgender health care. Until last March, a 1998 state regulation banned Medicaid coverage of all transition-related care.

In a notice posted Tuesday, the state health department said medically necessary hormone treatment and surgeries for transgender youths are covered by Medicaid.

In November, a federal judge ruled in a class-action lawsuit that New York must extend coverage to transgender people under 18. The health department said the lawsuit didn’t influence its decision to change its rules.

At the heart of the case is an ongoing national debate about whether health insurance should cover treatments that allow young people to change genders and, more broadly, whether care that changes the body is cosmetic or medically necessary.

Transgender advocates say such medications and surgeries treat gender dysphoria, the feeling that gender identity doesn’t match biological sex. They say patients, including children, can experience these feelings so deeply that they become depressed or even suicidal.

The original lawsuit was filed in June 2014 by the Legal Aid Society, Willkie Farr & Gallagher LLP and the Sylvia Rivera Law Project against the state Department of Health. In March 2015, the state health department lifted the ban, though Medicaid still didn’t cover all procedures. Over the next 18 months, the state gradually included more treatments.

But the health department opposed extending Medicaid coverage to transgender youths. Lawyers for the health department argued the medical community hadn’t reached a consensus on whether medications and surgeries intended to treat gender dysphoria were safe or effective for minors.

In particular, the medical materials presented by each party differed on what surgeries are necessary, U.S. District Judge Jed Rakoff said.

Because of the disagreement, Judge Rakoff decided the case should go to trial on the age matter. Then eight days before the trial, the health department notified the public it would change the policy.

Lawyers for the health department asked the judge not to issue a ruling. They listed the department’s solicitation of public comment on the proposed regulation as a reason.

At an October hearing, Judge Rakoff questioned the reasoning for the request, saying, “If, as a matter of constitutional law, a black child was entitled to be admitted to the schools of Little Rock, Ark., after the Brown v. Board of Education decision, the Arkansas Legislature could not, I think with a straight face, say, ‘We’ll wait till our procedure plays itself out.’ ”

About the state’s previous changes, he said: “In fact, one might make the argument it’s only when the court has pushed this case forward that they have reconsidered their previous position.”

In November, the judge handed down his decision.

This week, a health department spokeswoman said the regulation would make “transgender care and services available, regardless of an individual’s age, when such care and services are medically necessary to treat the individual’s gender dysphoria.”

The Wall Street Journal
‘I’ve Always Felt Like I’ve Been a Girl’
By Corinne Ramey
December 6, 2016

NORWICH, N. Y.—By the time John Ballard reached his teens, he had threatened to kill himself with broken glass, had temper tantrums in school and was in and out of a hospital crisis unit.

The summer after seventh grade, he taped a note to the steering wheel of his mother’s van: “Mom, I love you and everything you’ve done for me. I don’t want you to hate me after this, but I’ve always felt like I’ve been a girl.”

John’s mother told him she loved him and he would always be her child. She also took him to a doctor who prescribed medication to stall the onset of puberty.

But Medicaid wouldn’t pay for the drugs. About a month after being denied Medicaid coverage, John received the medication through a pharmaceutical company’s “compassionate use” program.

Today, John is 15 years old and goes by Mia. She was a plaintiff in the class-action lawsuit that successfully challenged New York restrictions on Medicaid gender-transition care. Transgender youths will be covered by Medicaid beginning Wednesday, health officials said.

Puberty blockers like the one that Mia takes can cost more than $25,000 a year, said Carolyn Wolf-Gould, her doctor in Oneonta, N.Y.

Mia’s mother, Alaina Randle, 34, is a single mother of three who worked at an aerospace manufacturing factory that relocated to Mexico. She is now planning to attend cosmetology school.

“It will make a real difference,” said Dr. Wolf-Gould, who said she treats about a half-dozen pediatric transgender patients who are covered by Medicaid.

For young people already questioning their gender, the onset of puberty can trigger depression or suicidal thoughts, said John Steever, a pediatrician at Mount Sinai Adolescent Health Center in Manhattan.

“If you consider yourself a girl and you’re getting erections a lot, this isn't a girl thing,” he said. “It can be distressing.”

Puberty blockers, whose effects can be reversed, buy a teenager more time since about half of children with gender dysphoria outgrow it, Dr. Steever said. The other half typically begin taking hormones at age 15 or 16 that initiate puberty of their desired gender, he added.

Mia no longer threatens to kill herself and is doing well in school. She wears makeup, tinkers with engines and plays Elvis’s “Can’t Help Falling in Love” on her ukulele.

She has been bullied in class. “A girl kept saying to Mia, ‘If you have a penis you’re a boy, so you need to act like a boy,’ ” said her grandmother, Janine Carpenter, 54. Both her mother and grandmother have fiercely defended her.

Sitting in her living room with a white chinchilla named Yoda, Mia’s mother pointed to photos of John as a toddler in overalls and a straw hat. For the family, his transition to Mia was a relief, she said, adding: “And I gained a girl out of it.”