MO bill would bar Medicaid from covering gender

When Missouri lawmakers approved a bill this month banning gender-affirming care for minors, it included a provision that would prohibit Medicaid from covering transgender-related health care for people of all ages.

The provision is tucked in a bill sitting on Republican Gov. Mike Parson's desk. It prevents Missouri's Medicaid program, called MO HealthNet, from paying for surgeries, hormones or puberty-blockers "for the purpose of a gender transition."

Parson, a Republican who threatened to call lawmakers into a special session if they did not pass the bill this year, is expected to sign the legislation into law this summer. Parson's signature could come in the next few weeks during Pride Month, which commemorates the struggle for LGBTQ rights.

While much of the debate on the legislation, from lawmakers, lobbyists and advocates, has centered around the ban on gender-affirming care for minors, the Medicaid provision would also affect adults in Missouri. And another provision would ban gender-affirming surgeries in jails.

"It's evidence that it's not really just about protecting children, but it's about attacking transgender people of all ages with whatever tools are available," said Brandon Barthel, a Kansas City-based endocrinologist who provides care for transgender adults.

While the MO HealthNet program typically does not currently cover gender-affirming surgeries, it can cover treatments such as hormone therapy, doctors told The Star.

The Missouri Medicaid program covers mental health counseling while Kansas covers voice/communication therapy, according to a 2021 survey of state Medicaid coverage by the nonprofit health policy group Kaiser Family Foundation.

Matt Lara, a spokesman for the Kansas Department of Health and Environment, said in an email that Kansas does not have any regulations restricting the use of Medicaid dollars for gender-affirming care.

Under the Missouri bill, surgeries, hormones and puberty-blockers for gender-affirming care would be barred from the program, which provides health coverage for low-income and disabled Missourians. The bill does not explicitly mention barring Medicaid from covering counseling or therapy for gender-affirming care.

"It's just a matter of the state, you know, deciding where it's going to spend its money," Senate President Pro Tem Caleb Rowden, a Columbia Republican, told reporters earlier this month. "We don't think it's in the best interest of the state and the taxpayer."

Ryan Cox, a psychologist for transgender adults in Kansas City, said that about 20% of the patients at his clinic are on Medicaid. The program typically covers office visits, labs and medications for patients seeking gender-affirming care, he said.

However, he said some patients have had trouble getting Medicaid to cover gender-affirming hormones. While hormones are usually affordable and many patients end up paying out of pocket, some can't, he said.

"You’re talking about people who are on Medicaid," he said. "If they’re on Medicaid, they’re at a lower socio-economic status already. So, that creates a greater medical burden on those individuals."

State Sen. Mike Moon, an Ash Grove Republican who sponsored the bill, told The Star that the bill's effect on adults was something he "hadn't really considered." Moon has frequently touted his bill as a way to protect kids.

Moon, in an interview with The Star, defended barring Medicaid from covering gender-affirming care.

"If a person is wanting to make a change, reassignment surgeries and that sort, it should be their expense," he said. "When you’re receiving benefits that taxpayers are providing, it should be something that is for basic necessities."

Missouri Attorney General Andrew Bailey also attempted to effectively ban gender-affirming care for adults and kids through an emergency rule. Bailey, a Republican, withdrew the rule after lawmakers passed the ban on care for minors last month.

The bill has the potential to severely restrict transgender Missourians’ access to affordable care. Because of job and personal discrimination, trans people are less likely to be employed or may be in low-wage jobs and are more likely to rely on Medicaid, said Sidney Watson, a professor at the Center for Health Law Studies at St. Louis University.

"We know that in the LGBTQ community, they disproportionately rely on Medicaid because of lower incomes, because of various forms of discrimination," she said.

Cox said he believes that the bill violates anti-discrimination provisions in the Affordable Care Act, signed into law by then-President Barack Obama in 2010. The act prohibits health programs from discriminating on the basis of race, color, national origin, age, disability or sex — including sexual orientation, gender identity and sex characteristics.

He believes a lawsuit will challenge the bill if Parson signs it into law. If signed, the law would go into effect on Aug. 28.

But, for now, doctors and health providers are stuck in an anxious waiting period where they don't know how exactly the legislation will affect coverage or care. Cox said he's had to have some tough conversations with patients.

"What I’ve been telling them the last three months, for all of us, is I just don't know," he said. "I wish I had a better answer than that, but we don't know at this point exactly what it's going to change."

Cox said someone who is medically transitioning would still be able to come to his clinic and get primary care and psychological care. But they wouldn't be able to use Medicaid to pay for an endocrinologist who was prescribing their hormone therapy.

Ben Grin, an assistant professor of primary care at Kansas City University and a primary care doctor at the KC CARE Health Center, said the bill would make gender-affirming treatments less accessible for patients. Grin, who provides some gender-affirming care to adults, said transgender patients in the MO HealthNet program will likely have to seek alternate options to pay for their medications.

As a primary care doctor, Grin said he tries to find creative solutions for patients who face financial challenges. One option is GoodRx, which provides coupons that patients can bring to pharmacies for discounts on medications.

Watson, the SLU health professor, said Medicaid coverage for children and adolescents is supposed to be broad. Under the benefit called Early and Periodic Screening, Diagnostic, and Treatment, state Medicaid programs must cover all medically necessary, non-experimental treatments for children, she said.

She said that could cause the bill to run into legal issues.

Tom Bastian, a spokesperson for the ACLU of Missouri, which previously sued Bailey over his emergency rule aimed at trans adults, said in a statement that the bill "goes far beyond the fabricated concern for children and removes access to life-saving gender-affirming health care from adults based on the amount of money they earn or past mistakes."

"Courts have found, over and over, that the defenses of these types of bans simply fail," the statement said.

For some patients, just hearing about the legislation will prevent them from seeking care, said Barthel, the Kansas City-based endocrinologist.

"Just the knowledge that everything's under attack, and then the potential for misunderstanding or misinformation, is going to keep some people away," he said. "I think you definitely can already see people moving."

This story was updated to include a comment from the Kansas Department of Health and Environment.

The Star's Katie Bernard contributed reporting.