I’m seeing a bunch of posts that make me think most USAmericans don’t know about The No Surprises Act.
It was passed in 2021 (thank you Biden) and essentially states that if you don’t have insurance or your insurance doesn’t cover a service you need (or want) you are entitled to a Good Faith Estimate of the cost of care. (If your insurance does cover the service, you should be able to estimate the cost of care based on your deductible and co-pay.)
As a healthcare provider who does not accept any insurance, I am very careful to not violate The No Surprises Act. Why? Because for every penny more than $400 that the Good Faith Estimate was “off” (or if it wasn’t provided), you are entitled to a refund for that amount.
Y’all. Ask for a Good Faith Estimate. Get it in writing. Compare it to what you are paying. If you are not provided an estimate or if it’s wrong by more than $400, demand a refund.
I’m reforging this for the second time in five minutes because I needed to add that part of this is also about what your health insurance provider is required to do. They’re required to tell you what your out of pocket cost will be. If you contact them and they say actually they don’t know but your copay is X%, you can ask them to call the provider and get the codes they plan to use to bill for your services. If the provider is in network they’ll have negotiated rates in place so the insurer will know exactly how much you can be charged for that service and then they have to tell you. No surprise huge medical bills even if you are insured.
So today I want to talk about puberty blockers for transgender kids, because despite being cisgender, this is a subject I’m actually well-versed in. Specifically, I want to talk about how far backwards things have gone.
This story starts almost 20 years ago, and it’s kind of long, but I think it’s important to give you the full history. At the time, I was working as an administrative assistant for a pediatric endocrinologist in a red state. Not a deep deep red state like Alabama, we had a little bit of a purple trend, but still very much red. (I don’t want to say the state at the risk of doxxing myself.) And I took a phone call from a woman who said, “My son is transgender. Does your doctor do hormone therapy?”
I said, “Good question! Let me find out.”
I went into the back and found the doctor playing Solitaire on his computer and said, “Do you do hormone therapy for transgender kids?” It had literally never come up before. He had opened his practice there in the early 2000s. This was roughly 2006, and the first time someone asked. Without looking up from his game of Solitaire, the doctor said, “I’ve never done it before, but I know how it works, so sure.”
I got back on the phone and told the mom, who was overjoyed, and scheduled an appointment for her son. He was the first transgender child we treated with puberty blockers. But not, by far, the first child we treated with puberty blockers, period. Because puberty blockers are used very commonly for children with precocious puberty (early-onset puberty). I would say about twenty percent of the kids our doctor treated were for precocious puberty and were on puberty blockers. They have been well studied and are widely used, safe, and effective.
Well. It turned out, the doctor I worked for was the only doctor in the state who was willing to do this. And word spread pretty fast in the tight-knit community of ‘parents of transgender children in a red state’. We started seeing more kids. A better drug came out. We saw some kids who were at the age where they were past puberty, and prescribed them estrogen or testosterone. Our doctor became, I’m fairly sure, a small folk hero to this community.
Insurance coverage was a struggle. I remember copying articles and pages out of the Endocrine Society Manual to submit with prior authorization requests for the medications. Insurance coverage was a struggle for a lot of what we did, though. Growth hormone for kids with severe idiopathic short stature. Insulin pumps, which weren’t as common at the time, and then continuous glucose monitoring, when that came out. Insurance struggles were just part and parcel of the job.
I remember vividly when CVS Caremark, a pharmaceutical management company, changed their criteria and included gender dysphoria as a covered diagnosis for puberty blockers. I thought they had put the option on the questionnaire to trigger an automatic denial. But no – it triggered an approval. Medicaid started to cover it. I got so good at getting approvals with my by then tidy packet of articles and documentation that I actually had people in other states calling me to see what I was submitting (the pharmaceutical rep gave them my number because they wanted more people on their drug, which, shady, but sure. He did ask me if it was okay first).
And here’s the key point of this story:
At no point, during any of this, did it ever even occur to any of us that we might have to worry about whether or not what we were doing was legal.
It just never even came up. It was the medically recommended treatment so we did it. And seeing what’s happening in the UK and certain states in America is both terrifying and genuinely shocking to me, as someone who did this for almost fifteen years, without ever even wondering about the legality of it.
The doctor retired some years ago, at which point there were two other doctors in the state who were willing to prescribe the medications for transgender kids. I truly think that he would still be working if nobody else had been willing to take those kids on as patients. He was, by the way, a white cisgender heterosexual Boomer. I remember when he was introduced to the concept of ‘genderfluid’ because one of our patients on HRT wanted to go off. He said ‘that’s so interesting!’ and immediately went to Google to learn more about it.
I watched these kids transform. I saw them come into the office the first time, sometimes anxious and uncertain, sometimes sullen and angry. I saw them come in the subsequent times, once they were on hormone therapy, how they gradually became happy and confident in themselves. I saw the smiles on their faces when I gave them a gender marker letter for the DMV. I heard them cheer when I called to tell them I’d gotten HRT approved by insurance and we were calling in a prescription. It was honestly amazing and I will always consider the work I did in that red state with those kids to be something I am incredibly proud of. I was honored to be a part of it.
When I see all this transgender backlash, it’s horrifying, because it was well on the way to become standard and accepted treatment. Insurances started to cover it. Other doctors were learning to prescribe it. And now … it’s fucking illegal? Like what the actual fuck. We have gone so far backwards that it makes me want to cry. I don’t know how to stop this slide. But I wrote this so people would understand exactly how steep the slide is.
not to be anti-religious but i do wonder if teaching children that they are innately flawed and sinful is, perhaps, not a healthy worldvi
to expand on this, i also think kids should probably grow up without being told that engaging in common pleasurable activities is a sin against god
in fact i suspect that telling tiny vulnerable human beings they are morally obligated to forsake the needs and desires of the flesh, might, just possibly, interfere with healthy develo
Please don’t say religion when you mean Christianity. None of those are innate parts of religion.
so the language of the additions on this post was very consciously influenced by my experiences living in countries with laws and cultures dominated by Islam and Buddhism, respectively.
Yes I grew up in an oppressively Christian culture, but Western Christianity is not solely or even necessarily singularly oppressive, and is certainly not the only religious structure that leverages shame in a dangerous way. And we do the world at large a disservice by acting like other major global religious institutions are harmless simply because they aren’t Christian. Religious trauma comes in many forms, foreign and familiar.
