The End of the Public Health Emergency Could Leave Transgender People without Access to Vital Care
With the end of the Covid-19 Public Health Emergency (“PHE”), transgender people in the United States may find it more difficult to obtain critical health care, access vital medications – especially testosterone for trans men and other trans masculine people – and to receive other life-saving benefits.
Since the beginning of the PHE in early 2020, telehealth has become a crucial part of the American healthcare system, especially for transgender people living in rural areas, in states with hostile policies on transition-related care, or otherwise distant from an affirming healthcare provider. Through telehealth appointments, transgender people could attend appointments with expert providers without driving hours each way.
With the end of the PHE, many transgender people are rightly concerned that they will be unable to continue the care they have received for the past three years.
Unfortunately, how much their care will change depends on the type of care they receive, how they receive it, and who pays for it. Transgender people receiving care through in-person visits to a provider, paid for by either Medicare or private insurance are unlikely to see a significant impact to their care. Trans people receiving care through telemedicine or whose insurance coverage is provided by Medicaid, however, may find their care disrupted.
Post-PHE Telehealth Prescribing Rules
Restrictions on the use of telehealth were eased during the PHE, and with its end, some of them are coming back into place. Most notably, the Drug Enforcement Agency (“DEA”) issued emergency rules allowing for the prescription of controlled substances (including testosterone, a Schedule III controlled substance) through telehealth appointments. Initially, these temporary rules were set to expire with the PHE on May 11th, but on May 3rd the DEA announced it would temporarily extend the telehealth exemption while it considers public comments on a permanent rule, a draft of which was released in late February.
Under the DEA’s proposed February rule, healthcare providers would have been granted the ability to prescribe controlled substances like testosterone over telehealth appointments where the provider had previously seen the patient in-person, or the patient had been referred by another healthcare provider. Providers would have been able to prescribe an initial 30-day prescription of Schedule III to V controlled substances following a telehealth visit but would be required to have an in-person appointment with the patient before refills could be prescribed. A 180-day transition period was also included for patients who had begun care over telehealth during the PHE.
On March 31st, the National Center for Transgender Equality and 61 other organizations submitted a public comment to the DEA proposing changes to the draft rules. NCTE’s recommended changes included: 1) allowing all patients, not just those who had already begun care, to take advantage of the proposed 180-day transition period; 2) expanding the initial 30-day prescription prior to an in-person appointment to at least 90, and ideally 180, days; 3) allowing for appointments for lab work to qualify as the required in-person appointment; and 4) encouraging the DEA to work with other federal agencies on rescheduling testosterone to expand access.
While the full scope of the DEA’s final telehealth rules are not yet clear, transgender people who see their healthcare providers through telehealth visits and who are prescribed a controlled substance such as testosterone are highly encouraged to take steps now to schedule an in-person appointment as soon as practical in order to be fully covered by the final rules when they are released.
Medicare Restrictions on Telehealth Appointments Waived through 2024
Before the PHE, Medicare imposed significant restrictions on individuals' ability to see a healthcare provider through telehealth. Fortunately, a federal law passed in late 2022 ensures that the vast majority of these restrictions will continue to be waived through the end of 2024. As such, transgender people receiving coverage through Medicare should be able to continue receiving care through telehealth for at least the next 18 months.
Medicaid Unwinding Will Leave Millions without Coverage
During the PHE, states were prohibited from denying benefits from people who already received care through Medicaid. As a result, as of early 2023, more people than ever before received healthcare coverage through Medicaid, as eligibility requirements were waived or no longer verified for existing members. Beginning last month, however, states have begun reenforcing eligibility requirements, often with little notice, leaving millions at risk of losing healthcare coverage. In many cases, this has or will impact people who are eligible for Medicaid, but who are unable to respond to often complex bureaucratic requirements before their state’s deadline.
If you are a transgender person who currently receives healthcare through Medicaid, you are strongly encouraged to check what your state’s Medicaid unwinding process looks like and what you are required to submit to verify your eligibility. And, if you are no longer eligible for Medicaid, you should act quickly to apply for healthcare coverage through the federal or state Affordable Care Act healthcare marketplace.
Work Requirements May Be Back for Federal Food Assistance
The PHE also waived several restrictions on access to federal food assistance, including through the Supplemental Nutrition Assistance Program (“SNAP”), which includes work requirements that were in place in roughly half the states. If you receive SNAP benefits or other government food assistance, you should check local rules to verify what paperwork is now required to continue coverage.
The End of the PHE Comes at the Worst Time for Transgender People
The end of the PHE comes at the worst time for the transgender community. Unprecedented state-level attacks on trans people have left far too many individuals at risk of losing necessary healthcare and other lifesaving benefits, just as the ability to access care remotely through telehealth appointments is coming into question.
NCTE will continue to fight to ensure access to care for transgender people at both the state and federal level, to both defeat bans on access to transition-related care and to expand access to vital services like telehealth.