If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Eight days before my 33rd birthday in April, a social worker at a crisis clinic near Denver determined I was an imminent danger to myself. She placed me on an involuntary 72-hour mental health hold.

What came next wasn’t treatment, but a search for a bed. Clinic staffers called area hospitals with inpatient psychiatric units, asking if they had available beds. They didn’t. So, I was told I had to spend the night at the clinic, which is open 24/7. I settled into a recliner, trying to make myself comfortable as my mind drifted in a blank, disassociated haze. Sleep came in brief bursts.

Since the 1950s, the United States has seen a nationwide due in part to deinstitutionalization and the rise of antipsychotics. But that has created a critical shortage for those needing help. From 2011 to 2023, the number of hospitals with inpatient psychiatric units , according to a 2025 study. Another study from that year found that this country has 28.4 inpatient psychiatric beds per 100,000 people — not even half the 60-bed ratio researchers frequently refer to as the .

The shortage has created what the American Psychiatric Association : emergency rooms overwhelmed with people suffering from severe mental health illnesses, inpatient stays prematurely shortened to speed up bed turnover, and acutely ill individuals left without critical care.

“Where are these people going?” said , an assistant health policy professor at Rutgers University, who co-authored those 2025 studies. “For people who don’t receive this care, they don’t just go away. How is it affecting them? Society? Their families?”

Meanwhile, the White House shut down the part of the national suicide hotline catering to LGBTQ+ youth, President Donald Trump’s 2027 budget proposal calls for cuts to agencies , and Health and Human Services Secretary Robert F. Kennedy Jr. recently announced a plan to .”

A Fractured System

I was already intimately familiar with the country’s fractured mental healthcare system before I was involuntarily committed. What I had yet to experience myself, I saw through my wife: waitlists, outpatient programs stretched beyond capacity, and inpatient psychiatric care so scarce that access often depends on surviving a crisis severe enough to justify it.

She died by suicide after we had separated.

As the years passed, grief and anxiety pushed me from observer to patient.

At the crisis clinic, I woke up the following morning disoriented and groggy. In the bathroom — its door deliberately unable to latch, swinging both ways so staffers could enter in case of an emergency — I stood at the sink and watched the faucet run, trying to piece together how I had ended up here.

America’s history of treating mental illness is long and complicated.

The 19th and 20th centuries saw the removal of people with severe mental disorders from jails and — squalid facilities designed to house the poor — to state asylums that (though they ultimately became ). From the 1860s to the 1930s, the number of psychiatric hospitals increased dramatically, according to the American Psychiatric Association, and by 1955, the number of psychiatric beds in the U.S. peaked at more than half a million.

However, owing to the development of antipsychotics, the belief that psychiatric institutions were inhumane, and President John F. Kennedy’s 1963 to free thousands of Americans from a life in institutions, many state hospitals shut down. An estimated for adults and kids are left in a country where more than 14 million experience severe mental illness each year.

Two years after JFK’s legislation passed, a new policy prohibited federal Medicaid funds from covering inpatient psychiatric care in facilities . The goal was to encourage states to move patients out of large, often substandard psychiatric institutions into community-based care settings.

The consequences of these changes, however, have been far-ranging. People with severe mental illnesses are often forced to as they wait for a bed to open. The length of stay in state psychiatric hospitals , according to research by the Treatment Advocacy Center, a national organization focused on eliminating barriers to the treatment of severe mental illness. And some people with mental illness .

From 1986 to 2014, as the behavioral health crisis intensified, mental health expenditures in the U.S. rose from $32 billion to $186 billion — though the proportion of that spending allocated to inpatient care .

This period also recorded major policy shifts affecting inpatient hospitalization rates, notably the 1999 U.S. Supreme Court decision in Olmstead v. L.C. The ruling shifted care away from psychiatric facilities by mandating states to people with developmental and mental disabilities.

“The road to hell is paved with good intentions,” said Leslie Carpenter, legislative advocacy manager at the Treatment Advocacy Center. “A lot of these bills, including the Community Mental Health Act, were really well intended and ended up with adverse consequences.”

For me, that next day at the clinic passed both painfully slowly and in a blur. A staff member I hadn’t met before told me they were still reaching out to hospitals across the region. The search for a bed continued.

‘No One Wants To Pay for Any of This Care’

Last year, members of Congress introduced two bills to change the 16-bed Medicaid funding cap at inpatient psychiatric facilities, the and the , which would increase the cap to 36 beds. Both have stalled in the House.

According to the Congressional Budget Office, a federal agency that analyzes budgetary and economic issues, eliminating the 16-bed limit would increase Medicaid expenditures from 2024 to 2033.

“No one wants to pay for any of this care that people need,” said Colorado state Sen. , a Democrat who has witnessed limitations to Colorado’s mental healthcare system firsthand because her son has schizoaffective disorder.

In lieu of federal action, states are stepping up to bridge the gaps.

Colorado, 15 other states, and Washington, D.C., now operate under waivers allowing Medicaid to fund inpatient facilities for mental health treatment, according to KFF data. Seven additional states have waivers pending. One 2025 study found that these waivers may be tied to fewer hospitalizations, emergency department visits, and incarcerations .

Yet even local efforts to improve mental healthcare face resistance. In California, Colorado, Iowa, Missouri, Nebraska, and New York, locals have pushed back against proposed psychiatric facilities for minors, claiming such facilities will worsen safety and lower property values. Behavioral health advocates have disputed these claims and argued they are rooted in stigma.

That psychiatric facility in Colorado was . The state has nearly 20 inpatient beds per 100,000 people, , according to 2022 data across all 50 states plus Washington, D.C., collected by the Treatment Advocacy Center. Wyoming ranked first with 47.3 beds per 100,000 residents, although, as the least populous state, it has only 275 total inpatient beds compared with California’s 5,703. Minnesota ranked last, with only 4.3 inpatient beds per 100,000 residents.

While increasing the number of inpatient psychiatric beds is vital, mental health advocates are also calling for , such as peer support specialists and clubhouses, where people with serious mental illnesses can learn life skills and find community.

When it came time for me to use our mental health safety net, I was among the fortunate ones: At noon the day after my hold began, a bed opened at a hospital in Denver — a rare stroke of luck in a system in which many people wait days or weeks for the care they need. An ambulance transferred me to the hospital at 3 p.m., marking 21 hours into my 72-hour hold.

Two days later, on my last day at the psychiatric hospital, I stood outside the nurse’s station awaiting discharge papers.

A man I had not seen before looked at me and asked, “Are you leaving?”

“Yes,” I said. “Are you being admitted?”

“Yeah,” he responded. “This is my third time being hospitalized in a year.”

I shook his hand. “Good luck,” I said, and I walked out the door.

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Almost three weeks after Florida’s Republican governor, Ron DeSantis, signed a bill making it a felony for doctors to provide gender-affirming care to transgender minors, a judge issued a preliminary injunction preventing enforcement of the law for three children whose parents are part of an ongoing lawsuit.

Florida is one of at least 20 states that have . The legislators sponsoring some of these bills say their intent is to protect children and families from pressure “to receive harmful, experimental puberty blockers and cross-sex hormones and to undergo irreversible, life-altering surgical procedures,” as puts it.

“Gender transitions involving major surgeries not only result in sterility, but other irreversible negative biological effects,” said Montana state Sen. John Fuller, the Republican who introduced the bill.

Such laws and policies, and statements — such as Fuller’s — used to justify them, reflect misconceptions and misinformation that conflate treatments and strip trans youth of essential care.

Gender-affirming care is a broad term for many distinct treatments provided to children, teens, and adults. Puberty blockers, for example, are medications that inhibit puberty by suppressing the body’s production of sex hormones, while hormone therapy is the administration of testosterone or estrogen to alter secondary sex characteristics.

One common misbelief heard when legislation is discussed is that gender-affirming medical interventions are provided immediately to any trans or nonbinary kid who walks into a gender clinic.

The reality is that the process informing these treatments is a long and intensive one. Before any medical or surgical interventions, kids must first be , which, for prepubescent youth, involves experiencing significant distress for at least six months from at least six of a set of causes, including a strong desire to be of the other gender and a strong dislike of one’s sexual anatomy. Youth who have gone through puberty must meet two of the criteria for a diagnosis.

Providers also abide by the standards of care set by the World Professional Association for Transgender Health. These standards to perform a comprehensive assessment of a child’s or teen’s “strengths, vulnerabilities, diagnostic profile, and unique needs” before providing any medical or surgical interventions. Without this assessment, other mental health issues “that need to be prioritized and treated may not be detected.”

The time it takes to perform this assessment varies from patient to patient, said Jack Turban, an assistant professor of child and adolescent psychiatry at the University of California-San Francisco. Turban may see someone who is 12 years old and asking for puberty blockers. This hypothetical patient has known they are trans since they were 5 years old and has already adopted a new name and pronouns that match their gender identity.

“That’s going to be a much shorter assessment to know that they are ready for treatment when compared to somebody who has only understood their trans identity for six months” and has other complex mental health conditions like schizophrenia, Turban said.

To receive puberty blockers, kids must also have experienced the onset of puberty, or on the Tanner scale of developmental change. This is marked by physical changes like the development of breast buds or testicle growth and tends to happen between the ages of 9 and 14 in kids with testes and 8 and 13 in those with ovaries. By pausing puberty, these drugs buy children more time to explore their gender identity before undergoing permanent and potentially unwanted pubertal changes.

The age at which trans minors receive gender-affirming hormone therapy depends on the patient’s ability to provide informed consent for the treatment, which can happen when they’re as young as 12 or 13 years old. The Endocrine Society notes that to consent by the time they’re 16.

“We offer hormones to patients who are experiencing gender incongruence when patients and families are ready. This may be at an earlier age so that patients can go through puberty alongside their cisgender peers, or later, if they choose to,” said Mandy Coles, co-director of the Child and Adolescent Transgender Center for Health at Boston Medical Center. “If someone says, ‘I’m interested in estrogen,’ I say, ‘Great. What are the things that you are hoping to get out of that?’ Because it’s incredibly important to speak to patients and families about what medications can do, and what they can’t do.”

Coles said she also makes sure to talk continuously about consent with both the child and parents throughout the treatment process and lets her patients know they can stop taking hormones at any time.

Some physical changes by gender-affirming hormone therapy are reversible. For example, decreased muscle strength and body fat redistribution caused by estrogen can reverse once a person stops taking the hormone — though these changes become more fixed the longer someone stays on the hormone. However, breast growth from estrogen or a deepening of the voice caused by testosterone are not reversible.

If a trans person decides to receive gender-affirming surgery, clinics require that the individual receive letters from one or more providers stating they have persistent and well-documented gender dysphoria, any significant mental health concerns they have are sufficiently controlled, and they can consent to the surgery. For genital, or “bottom,” surgery, the letter may also need to state that the individual has been living full time in their “identified gender” for at least 12 months.

Most medical centers require individuals to be at least 18 years old for bottom surgery and chest, or “top,” surgery, though some do perform top surgery on younger teens if the patient, their parents, and health care providers agree the procedure is appropriate.

Much of the confusion is over puberty blockers, drugs that have been used for decades for children who enter puberty too early. A common assertion anti-trans groups and legislators make is that puberty blockers are dangerous and lead to infertility. This is not the case, said Coles. “Puberty blockers are fully reversible medications. They work like a pause button on puberty.”

Fertility may be impaired, however, in those who go straight from puberty blockers to hormone therapy, which is why the current medical guidelines require fertility counseling prior to any gender-affirming medical care, said Turban.

The FDA has not approved the use of puberty blockers for gender-affirming care. However, across all medications are for “off-label,” or unapproved, use — and the rate is even higher for prescriptions to children.

“We know that taking away the decision to use blockers from parents and providers leads to poor health outcomes for patients,” said Coles.

A study by Turban and colleagues found that trans adults who received puberty blockers during adolescence were than those who wanted puberty blockers but did not receive them.

The same benefits have been found with gender-affirming hormone therapy.

In a study of data from nearly 28,000 trans adults who responded to the , Turban and fellow researchers found that people who received gender-affirming hormone therapy during adolescence had than those who didn’t take hormones until they were adults.

Additionally, a study of 104 young trans and nonbinary patients at the Gender Clinic of Seattle Children’s Hospital found those who had started on puberty blockers or hormone therapy had of depression and 73% lower odds of self-harm or suicidal thoughts than peers who hadn’t received those treatments.

There is so much misinformation claiming that providers of gender-affirming care are permanently harming vulnerable children, said Coles. “Denying access to care harms transgender and gender-diverse kids,” she said. “Gender-affirming care is not new. It’s the attacks on care that are new.”

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would cap out-of-pocket copays at $60 for a two-pack of epinephrine autoinjectors. In 2007, the wholesale was about $47. Today, just under $636 at a Walgreens in Denver, according to GoodRx. At some pharmacies , which is still expensive for many people.

The bill is the latest example in a nationwide push by states to address the soaring prices of lifesaving drugs. New Hampshire passed a law in 2020 , and Rhode Island lawmakers this year. No state has capped what consumers pay for EpiPens, though the New Jersey Senate in June to do so; that measure is pending in the legislature’s lower house.

The average launch prices of drugs in the United States increased , according to a study published last year. Price increases can skyrocket even higher for items such as epinephrine autoinjectors, a market dominated by EpiPen maker Viatris, a global pharmaceutical company.

“If you have very little competition in the market, the way the U.S. drug pricing system works is that the manufacturers get to set the price at which they want to sell the drug, and they can increase it whenever they so choose,” said Erin Taylor, a senior health care policy researcher at Rand Corp., a global policy think tank. “One way to shift costs back to health plans and manufacturers, and to help patients pay less for their drugs, is to apply these caps.”

The Colorado legislation would cap EpiPen copays for both insured and uninsured people starting in 2024. Almost 566,000 Coloradans have life-threatening food allergies, according to the bill. People can also have severe reactions to insect bites, medications, and latex.

“The need for EpiPens doesn’t discriminate based on who you are,” said state Rep. Iman Jodeh, a Democrat who is sponsoring the bill. “This unfortunate trend we were seeing of lifesaving medication being completely unattainable or out of reach for people is something that we are really trying to put an end to.”

In 2019, Colorado became the first state to enact a law that set a $100 , a hormone that regulates the blood sugar of people with diabetes.

Since then, , have implemented laws limiting insulin costs. Congress imposed a $35 insulin copay cap for seniors on Medicare, and, in his recent State of the Union address, President Joe Biden called for .

“Insulin has been the poster child of copay caps,” said Geoffrey Joyce, director of health policy at the University of Southern California Schaeffer Center for Health Policy & Economics.

However, the caps are an imperfect solution to high prescription costs. Decreasing the price of a drug for some insurance members means increasing premiums for others, said Taylor. “A cap doesn’t lower the list price of the drug, so somebody else has to pick up the difference,” she said. Caps also don’t address why drugs are so expensive in the first place.

Drug manufacturers and pharmacy benefit managers, or PBMs — the go-between companies that negotiate with drugmakers on how much insurance plans and consumers will pay for drugs — both play a significant role in drug pricing, Joyce said. Besides pricing their products high enough to ensure a hefty profit, manufacturers often give PBMs a rebate in exchange for having their product included in the PBM’s list of preferred drugs, which influences what consumers buy. Rising rebates demanded by PBMs are for prescription drugs, according to a white paper by USC Schaeffer.

“Everybody has their hand in the trough,” said Joyce. In response to broader concerns about the drug pricing system, diabetes activists have been pushing for caps on insulin prices, not just copays.

It’s hard to say whether more states will follow Colorado’s lead and cap out-of-pocket costs for drugs like EpiPens, but there does seem to be a political appetite for controlling specialty drug costs, said Taylor.

“It bothers people fundamentally and ethically that these lifesaving drugs are inaccessible for people,” said Joyce. “People need access to these drugs.”

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The number of reports the Rocky Mountain Poison and Drug Safety office received of kids age 5 or younger exposed to marijuana in 2021. By 2021, this age group made up nearly half of all marijuana exposures — in which the drug is ingested, inhaled, or absorbed through the skin — reported to the office, which is part of the nonprofit Denver Health organization.

In each of those five years, children were most often accidentally exposed by eating edibles — gummies, cookies, drinks, and other products infused with the psychoactive chemical tetrahydrocannabinol, or THC — and not by inhaling smoke or consuming the drug in other forms, like capsules or tinctures. In 2017, 35 children age 5 or younger were unintentionally exposed to marijuana through edibles, compared with 97 in 2021. Exposures don’t necessarily mean the children were poisoned or overdosed, according to the poison and drug safety office.

Marijuana exposures among children are increasing nationwide, with Colorado playing a notable role in this trend. However, the federal government has yet to create uniform protocols, and Colorado health officials haven’t conveyed any plans to revise the regulations meant to prevent children from consuming marijuana.

“Marijuana laws and regulations are regularly evaluated by lawmakers, state agencies, local agencies and the various stakeholders,” Shannon Gray, a spokesperson at the Marijuana Enforcement Division, which regulates the marijuana industry in the state, wrote in an email to KHN. “A top priority is preventing youth access and to the extent we see opportunity in rules to address youth access, we do so.”

Since legalized recreational marijuana sales began in 2014, Colorado has implemented a handful of directives to stop children from mistaking these products for safe, delicious sweets.

Regulations state that:

• No edibles may be manufactured in the shape of a human, an animal, or a fruit.
• All edibles must be sold in child-resistant packaging.
• “Candy” or “candies” isn’t allowed on packaging.
• Advertising must not include cartoon characters, or anything else meant to appeal to children.
• The universal THC symbol (! THC) must be on all packaging and stamped on all edible products.

Data from Rocky Mountain Poison and Drug Safety does not distinguish between incidents involving marijuana sold by licensed retailers and those involving marijuana from sources that don’t follow the state’s packaging rules, state health department spokesperson Gabi Johnston told KHN.

When asked whether the mandates are effective, Gray said the Marijuana Enforcement Division has “observed material compliance with these regulations” among marijuana businesses.

Regulation changes could be considered, including those proposed by state legislators, Gray said. But no forthcoming bills concern edible mandates, according to Jarrett Freedman, spokesperson for the Colorado House of Representatives majority. Democrats control both houses of the state legislature.

One limitation of regulating marijuana packaging is that most children 5 and younger can’t read, said Dr. Marit Tweet, a medical toxicologist at the Southern Illinois University School of Medicine. And, she said, many parents don’t know how to store marijuana safely.

The state health department has worked to address this knowledge gap through its , established in 2014 to teach the public about safe, legal, and responsible cannabis use. One fact sheet advises parents to store marijuana in a locked area, keep products in child-resistant packaging, and avoid using marijuana around children.

Public health officials also launched in 2018 targeting new parents and adults who influence kids’ behavior. Between fiscal years 2015 and 2020, the department spent roughly $22.8 million on those efforts.

It’s hard to say exactly how well marijuana regulations in states like Colorado are working, said Tweet. “It’s possible if those regulations weren’t in place that the numbers would be even higher.”

What’s happening in Colorado is part of a national trend. In a study published in January, researchers looked at the number of children younger than 6 who ingested marijuana edibles nationwide from 2017 to 2021. They found 207 reported cases in 2017. In 2021, , according to data from the National Poison Data System.

The legalization of cannabis has likely played a significant role in the rise of accidental child exposures, said Tweet, a co-author of the study. “It’s more readily available and more of an opportunity for the children to get into.”

Parents may also feel less stigma nowadays in reaching out to poison centers and health clinics, she said.

To understand what factors are driving these numbers, more research is needed into marijuana regulations and the number of child exposures nationwide, said Tweet.

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As a transgender woman, Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’”

So Rainey drives around 170 miles round trip every six months to get a supply of estrogen from a clinic in Memphis, Tennessee, to take home with her.

The obstacles Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural U.S. often face: a general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Dr. Morissa Ladinsky, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama-Birmingham.

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states in the U.S. live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, , a nonprofit think tank at the UCLA School of Law.

One in 3 trans people in rural areas in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. Additionally, a third of all trans individuals report having to teach their doctor about their to receive appropriate care, and 62% worry about being negatively judged by a health care provider , according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as all transgender adults to .

In Colorado, for example, many trans people outside Denver . Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first . As of 2018, 76% of medical schools included , with half providing three or fewer classes on this topic.

Perhaps because of this, almost in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use .

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Dr. Justin Bailey, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or , has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Dr. Caroline Kirsch, director of osteopathic education at the University of Wyoming Family Medicine Residency Program-Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide . For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the . After growing pressure from Tennessee’s Republican lawmakers, the clinic on patients younger than 18, potentially leaving many trans kids without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”

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Electrolysis is a common procedure among transgender people like Chevalier, a software developer in Oakland, California. In some cases, it’s used to remove unwanted hair from the face or body. But it’s also required for a phalloplasty or a vaginoplasty, the creation of a vagina, because all hair must be removed from the tissue that will be relocated during surgery.

Chevalier’s insurer, Anthem Blue Cross, told him he needed what’s known as a prior authorization for the procedure. Even after Chevalier received the authorization, he said, his reimbursement claims kept getting denied. According to Chevalier, Anthem said the procedure was considered cosmetic.

Many trans patients have trouble getting their insurers to cover gender-affirming care. One reason is transphobia within the U.S. health care system, but another involves how medical diagnoses and procedures are coded for insurance companies. Nationwide, health care providers use a list of diagnostic codes provided by the International Classification of Diseases, Tenth Revision, or ICD-10. And many of those, advocates for transgender people say, haven’t caught up to the needs of patients. Such diagnostic codes provide the basis for determining which procedures, such as electrolysis or surgery, insurance will cover.

“It’s widely regarded that the codes are very limited in ICD-10,” said Dr. , medical director of the at Children’s Hospital Los Angeles.

She advocates for a move to the 11th edition of the coding system, which was endorsed by the World Health Organization in 2019 and began to be adopted around the globe in February. Today, more than .

The new edition has like “transsexualism” and “gender identity disorder” with “gender incongruence,” which is no longer classified as a mental health condition, but as a sexual health one. This is crucial in reducing the stigmatization of trans people in health care, said Olson-Kennedy.

A move away from the mental health classification may also mean more coverage of gender-affirming care by insurance companies, which sometimes question mental health claims . WHO officials have said they hope that adding gender incongruence to a sexual health chapter will “help increase access to care for health interventions” and “destigmatize the condition,” .

However, history suggests that ICD-11 likely won’t be implemented in the U.S. for years. The WHO first endorsed ICD-10 in 1990, but the U.S. didn’t implement it for .

Meanwhile, patients who identify as transgender and their doctors are spending hours trying to get coverage — or using crowdfunding to cover big out-of-pocket bills. Chevalier estimated he has received 78 hours of electrolysis at $140 per hour, costing $10,920.

Anthem spokesperson Michael Bowman wrote in an email that “there has been no medical denials or denial of coverage” because Anthem “preapproved coverage for these services.”

However, even after the preapproval was given, Anthem responded to Chevalier’s claims by stating the electrolysis would not be reimbursed because the procedure is considered cosmetic, rather than medically necessary. This is regardless of Chevalier’s diagnosis of gender dysphoria — the psychological distress felt when someone’s biological sex and gender identity don’t match — which many doctors consider a medically legitimate reason for hair removal.

Bowman wrote that “once this issue was identified, Anthem implemented an internal process which included a manual override in the billing system.”

Still, Chevalier filed a complaint with the California Department of Managed Health Care, and the state declared Anthem Blue Cross out of compliance. Additionally, after KHN started asking Anthem questions about Chevalier’s bills, two claims that had not been addressed since April were resolved in July. So far, Anthem has reimbursed Chevalier around $8,000.

Some procedures that trans patients receive can also be excluded from coverage because insurance companies consider them “sex-specific.” For example, a transgender man’s gynecological visit may not be covered because his insurance plan covers those visits only for people enrolled as women.

“There is always this question of: What gender should you tell the insurance company?” said Dr. Nick Gorton, an emergency medicine physician in Davis, California. Gorton, who is trans, recommends his patients with insurance plans that exclude trans care calculate the out-of-pocket costs that would be required for certain procedures based on whether the patient lists themselves as male or female on their insurance paperwork. For example, Gorton said, the question for a trans man becomes “what’s more expensive — paying for testosterone or paying for a Pap smear?” — since insurance likely won’t cover both.

For years, some physicians helped trans patients get coverage by finding other medical reasons for their trans-related care. Gorton said that if, for instance, a transgender man wanted a hysterectomy but his insurance didn’t cover gender-affirming care, Gorton would enter the ICD-10 , into the patient’s billing record. Pelvic pain is a legitimate reason for the surgery and is commonly accepted by insurance providers, Gorton said. But some insurance companies pushed back, and he had to find other ways to help his patients.

In 2005, California passed a that prohibits discrimination by health insurance on the basis of gender or gender identity. Now, 24 states and Washington, D.C., forbid private insurance from .

Consequently, Gorton no longer needs to use different codes for patients seeking gender-affirming care at his practice in California. But physicians in other states are still struggling.

When Dr. , an internist and pediatrician at , treats a trans kid seeking hormone therapy, he commonly uses the ICD-10 code for “medication management” as the primary reason for the patient’s visit. That’s because Indiana has no law providing insurance protections for LGBTQ+ people, and when gender dysphoria is listed as the primary reason, insurance companies have denied coverage.

“It’s frustrating,” Meininger said. In a patient’s billing record, he sometimes provides multiple diagnoses, including gender dysphoria, to increase the likelihood that a procedure will be covered. “It’s not hard usually to come up with five or seven or eight diagnoses for someone because there’s lots of vague ones out there.”

Implementing ICD-11 won’t fix all the coding problems, as insurance companies may still refuse to cover procedures related to gender incongruence even though it is listed as a sexual health condition. It also won’t change the fact that many states still allow insurance to exclude gender-affirming care. But in terms of reducing stigma, it’s a step forward, Olson-Kennedy said.

One reason the U.S. took so long to switch to ICD-10 is that the American Medical Association strongly opposed the move. It argued the new system would put an incredible burden on doctors. Physicians would have to “contend with 68,000 diagnosis codes — a five-fold increase from the approximately 13,000 diagnosis codes in use today,” the AMA . Implementing software to update providers’ coding systems would also be costly, dealing a financial blow to small medical practices, the association argued.

Unlike past coding systems, ICD-11 is fully electronic, with no physical manual of codes, and can be incorporated into a medical facility’s current coding system without requiring a new rollout, said Christian Lindmeier, a WHO spokesperson.

Whether these changes will make the adoption of the new edition easier in the U.S. is yet to be seen. For now, many trans patients in need of gender-affirming care must pay their bills out-of-pocket, fight their insurance company for coverage, or rely on the generosity of others.

“Even though I did get reimbursed eventually, the reimbursements were delayed, and it burned up a lot of my time,” Chevalier said. “Most people would have just given up.”

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The patient — a 78-year-old man — was experiencing atrial fibrillation, . But for patients like this one with chronic health conditions, a history of cardiac issues and high blood pressure, the condition can cause a stroke or heart failure.

Workers from rolled the patient, who was on a gurney, out of the hospital and into the frigid night air. AnnieGrace Haddorff, the emergency medical technician on call, helped load the patient into the ambulance and jumped into the driver’s seat. Paramedic Alec Newby got into the back and hooked the patient up to a blood pressure cuff; a pulse oximeter, which measures heart rate and blood oxygen saturation; and an electrocardiogram, which records the heart’s electrical activity.

“Your heart is obviously pissed off,” Newby told the man as the ECG confirmed the atrial fibrillation.

The ambulance pulled onto U.S. Highway 50 for the one-hour-and-15-minute drive past clusters of homes among rolling hills of sagebrush, the expansive Blue Mesa Reservoir and the gaping Black Canyon of the Gunnison, with its craggy spires.

The patient was stable enough for the long drive, which covered only a sliver of GVH Paramedics’ 4,400-square-mile service area. It is more than twice the size of Delaware and is the largest response zone for an ambulance service in all of Colorado. A typical fire or emergency medical service response area ranges from 100 to 400 square miles.

In recent years, interfacility transports or transfers, also known as IFTs, like this one have become increasingly common for GVH Paramedics, forcing the team to drive far outside its already vast zone. Before the pandemic, the number of transfers rose because the population of Gunnison County was steadily increasing, more tourists were being drawn to places like the popular Crested Butte ski resort, and GVH Paramedics had expanded its services to larger metropolitan hospitals outside Gunnison County.

But now the team is being called to move patients more frequently, and greater distances, because the hospital beds in the relatively close cities of Montrose and Grand Junction are filled with covid-19 patients. The team is regularly required to drive patients to Denver, which is around three hours and 40 minutes from Gunnison.

Officials from the ambulance service worry that they might find themselves unable to respond to an emergency because their resources, which include six ambulances but only enough staff to operate three of those vehicles, are tied up on a long-haul transfer.

What were once 2½- or three-hour trips to Montrose are now far longer excursions, “and that takes resources from this community,” said CJ Malcolm, chief of emergency services. “We were doing that pre-covid, but now the state is so impacted, it’s like a daily part of our lives.”

Before the pandemic, all the ambulances would be simultaneously out on 911 calls or IFTs fewer than 10 times a year. Now, Malcolm said, it is happening with greater frequency. In those cases, GVH Paramedics leans on the emergency response team in Crested Butte, about 28 miles from Gunnison, or the response to the patient is delayed.

In 2018, GVH Paramedics made 166 IFTs, requiring nearly 40,000 miles of travel and a total of 987 hours of ambulance operation, according to data collected by the team. Last year concluded with 260 IFTs, over 70,000 miles of travel and a total of 1,486 hours of ambulance operation. That’s a 50% increase in time on the road.

“Anytime we have one or two ambulances out on an IFT, this leaves a massive tract of land with only one ambulance to respond,” Malcolm said. “This is a moderately terrifying position to be put into when we can easily have two or three 911 calls in a row.”

In August, for example, Gunnison Valley Health hospital transferred more than 60 patients, 37 of whom were transported by GVH Paramedics. That means that at least once a day that month, a GVH Paramedics crew was taking a patient out of town, Malcolm said. And if crew members aren’t scheduled to be back in Gunnison by 1 a.m., they must spend the night in a hotel to avoid driving along treacherous mountain roads while overly tired.

GVH Paramedics’ service area covers almost all of Gunnison County, a large portion of Saguache County and sections of Montrose and Hinsdale counties. It contains mountain ranges, canyons and wide expanses of high desert. With around 6,600 full-time residents and a university, Gunnison is the largest town the team serves. The surrounding towns — including Tin Cup, Pitkin and Ohio City — are villages with a couple of hundred people or former mining towns where the artifacts from the boom times outnumber the residents.

GVH Paramedics’ 21 full-time staff members and 10 to 20 individuals who work as needed have certifications in wildland firefighting and backcountry medicine skills, including swift-water, ice and avalanche rescue. To deal with the increased demands from IFTs, they have added an extra staff member to each shift, and off-duty staffers are being called in to assist.

As the pandemic drags on, the number of IFTs will probably continue to increase. By mid-November, the number of people in the hospital with covid-19 in Colorado was , approaching the December 2020 peak of 1,847. Hospitalizations remained above 1,500 through the end of the month. As a result, 93% of the state’s acute care hospital beds and 94% of ICU beds were being used as of Nov. 30, according to data from the .

“I don’t think we see the capacity concerns easing anytime soon,” said Cara Welch, senior director of communications at the Colorado Hospital Association.

Adding to the strain are people seeking care they delayed because of the pandemic and other respiratory viruses, such as respiratory syncytial virus, circulating in the state, Welch said.

Kelly Thompson, chief of operations of CareFlight of the Rockies, an air ambulance service that operates in Colorado and other parts of the West, agreed with this assessment. “We’ve already been transporting large numbers of kids with RSV that are sick, and you have covid on top of all of this,” Thompson said. “It’s a big concern. This is the time when we have a lot of sick people.”

In early November, to manage escalating concerns about hospital capacity, Colorado hospitals and health systems — the highest level. That means covid and non-covid patients can be moved without their consent from a hospital that doesn’t have enough capacity to one with more space. Hospitals can also send sicker patients to medical centers with more specialized care.

As the GVH Paramedics crew members approached Montrose with their patient over the recent holiday weekend, Newby called the hospital to let the staff know they were arriving. They pulled up to the emergency room entrance, and Newby and Haddorff rolled the patient into a hospital room. The Montrose hospital staff took over, moving the patient from the gurney to a hospital bed as Newby updated them on the patient’s medical records.

Soon they were back in the ambulance, headed for home. “IFTs can be stressful,” said Haddorff as she maneuvered the twisty mountain road bathed in moonlight.

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That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in Colorado’s Affordable Care Act marketplace. We discovered that our new insurance from Anthem doesn’t cover Depo-Estradiol and it would cost $125 out-of-pocket per vial. With both of us — and our four pets — depending heavily on Ky’s weekly $649 unemployment check, such medical expenses proved difficult. And , those unemployment checks ran out.

“I’m absolutely stressed. I don’t know what to do,” Ky said in August as we tried to find a solution.

Because of Ky’s physical transition as a transgender woman, her body doesn’t make the testosterone it once used to. So, without the medication, she would essentially go through menopause. A decline in estrogen levels can also cause transgender women to lose the physical transitions they’ve achieved, resulting in gender dysphoria, which is psychological distress from the mismatch between their biological sex and their gender identity.

Unfortunately, Ky’s experience is shared by many other transgender Americans. The covid-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults, who reported at higher rates . Consequently, enrollment surged in ACA plans and Medicaid, the . Yet many of those plans don’t fully cover gender-affirming care, partly because of conservative policies and lack of scientific research on how crucial this care is for transgender patients.

According to a survey by Out2Enroll, a national initiative to connect LGBTQ people with ACA coverage, 46% of the 1,386 silver marketplace plans polled cover all or some . However, 7% have trans-specific exclusions, 14% have some exclusions, and 33% don’t specify.

“It’s this whack-a-mole situation where plans for the most part do not have blanket exclusions, but where people are still having difficulty getting specific procedures, medications, etc., covered,” said Kellan Baker, executive director of the , a nonprofit that focuses on LGBTQ research, policy and education.

Twenty-three states and Washington, D.C., include gender-affirming care in their Medicaid plans. But . In 2019, an estimated , a number that has likely grown during the pandemic.

Yet even in states such as California that require their Medicaid programs to cover gender-affirming care, patients still struggle to get injectable estrogen, said Dr. , an internist who founded the . While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must request treatment authorizations to prove their patients need the drug. Weiner said those are rarely approved.

Such “prior authorizations” are an issue across Medicaid and ACA plans for medications including injectable estrogen and testosterone, which is used by transgender men, Baker said.

The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed for transgender women to physically transition, isn’t commonly used by non-trans women undergoing hormone therapy to treat menopause or other issues, Weimer said.

It also may be because cheaper options, including daily estrogen pills, exist, but these increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said. Consequently, many of Weimer’s patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get monthly.

While such insurance gaps have existed for long before the pandemic, the current crisis seems to have amplified the matter, according to Weimer.

The ACA prohibits discrimination based on race, color, national origin, age, disability and sex in health programs and activities that receive federal financial assistance. The Trump administration significantly narrowed the power of that provision, including eliminating .

However, in June 2020, before the Trump regulations could take effect, the Supreme Court ruled in , that employment discrimination based on sex includes sexual orientation and gender identity.

This landmark decision has served as a crucial tool to address LGBTQ discrimination in many aspects of life, including health care. As of July, for example, after Swan Being, a transgender woman, won a class-action lawsuit that relied in part on the Bostock decision.

The Biden administration announced in May that the U.S. Department of Health and Human Services Office for Civil Rights will in its enforcement of the ACA’s anti-discrimination provision. The next month, Veterans Affairs health benefits were expanded to include .

But for now, the pressure is still on patients like Ky to fight for their health benefits.

Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of covered drugs for its ACA plans, though many of its private employer-sponsored plans cover it.

Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls — and just before unemployment ran out — Anthem finally authorized her Depo-Estradiol. That brings her out-of-pocket cost to $60 per vial for the next year. It’s still expensive for us right now, but we’ll find a way to make it work.

“The reality is that trans people are more likely to be in poverty and don’t have the time or knowledge to spend four months fighting to get their estradiol like I did,” Ky said.

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