When Burtonsville resident Camila Reynolds-Dominguez realized she was transgender, she was terrified she wouldn’t be able to afford gender-affirming health care. The situation became even more fraught after she could no longer stay on her parents’ insurance.
Now a law student at the University of Maryland Baltimore Francis King Carey School of Law, Reynolds-Dominguez, who is in her twenties, is able to access private insurance. But she said she feels lucky and privileged that this is the case, and is working to make sure no transgender Marylander has to go through the uncertainty she did.
“If I wasn’t on the health care that I’m on, I certainly wouldn’t be doing as well as I am today. I wasn’t really like the best me that I could be. I wouldn’t have been able to afford that unless I had gotten into law school. And that’s such a precarious position to be in,” said Reynolds-Dominguez, who also works as a legal and policy intern at FreeState Justice, a Maryland LGBTQ advocacy nonprofit, and is part of the Trans Rights Advocacy Coalition, a group that advocates for trans rights in Maryland.
Amid a rise in anti-trans legislation sweeping the country, trans advocates and allies have been lobbying the state General Assembly to pass a bill sponsored by Montgomery County-based Del. Anne Kaiser (D-Dist.14) that would require Maryland Medicaid to cover gender-affirming care for transgender residents. The bill, HB283/SB460, is backed by 59 co-sponsors, including the majority of the Montgomery County delegation. The legislation would enable Marylanders without private insurance to obtain comparable gender-affirming care.
The bill passed the Senate Monday night, after passing the House of Delegates Saturday. The bill will have to be signed into law by Democratic Gov. Wes Moore. Advocates expect Moore will sign the bill, given his noted support of LGBTQ rights.
“I do feel a responsibility to advocate for people who can’t afford this care because I know how life changing it is for me and just because you can’t afford it is not a reason to not have access to the care,” Reynolds-Dominguez said.
About 0.5% of Maryland’s adult population–24,000 people–is transgender, and an estimated 6,000 trans Marylanders rely on Medicaid, according to a study from the Williams Institute at UCLA.
“By attaining these services, it’s been shown that discrimination and harassment go down, which lets people work more productively. You can have more stable access to housing because of this care. It reduces suicide discrimination, abuse, harassment. For all those reasons, this bill is very necessary,” Reynolds-Dominguez said.
The federal government has named gender-affirming care as an “essential health benefit” protected under Section 1557 of the Affordable Care Act, so if the bill is passed, it would bring Maryland up to federal compliance. This standard has been upheld in federal district courts and is backed by the Centers for Medicare and Medicaid Services, as well as the American Medical Association, the American Psychiatric Association and the American Academy of Pediatrics.
According to the legislation, gender-affirming care can include:
- hormone therapy, hormone blockers and puberty blockers
- surgery and alterations to various parts of the body to align with gender identity
- laser treatment for scars from gender-affirming surgeries
- voice therapy
- other treatments prescribed to align the appearance of the physical body with gender identity
“Ultimately, this bill is about equity,” Kaiser said. “What we’ve tried to do in Maryland in the past, is to ensure that Maryland Medicaid covers things that private insurance covers. We’re trying to provide something that people already get with private insurance.”
Kaiser represents parts of Olney, Laytonsville and Damascus. Other states including Virginia, Alaska, Colorado, Oregon, Massachusetts, Connecticut, Washington, California and New York as well as Washington, D.C., have passed similar bills.
“Maryland is this allegedly blue state, but we’re one of the only ones that has these exclusions for trans health care,” Reynolds-Dominguez said. “Maryland needs to show up and do the bare minimum that other states are doing. … Guaranteeing that all Marylanders have access to this care, regardless of their income, sends a very clear message that Maryland supports trans people.”
If passed, services are estimated to cost 0.005% of the state’s Medicaid budget, and in 2022, 98 individuals received gender-affirming treatment through Medicaid, according to a fiscal policy note on the bill.
A long road with barriers
The legislation has received the backing of the Montgomery County Council, which included the bill in the legislative priorities the body submitted to the General Assembly this year.
For Councilmember Kate Stewart (D-Dist. 4), it’s personal. As the mother of a transgender son, she’s experienced the difficulties of accessing gender-affirming care, and she wants it to be easier for her constituents. Stewart said there are barriers to accessing gender-affirming care, even in an area like Montgomery County that many consider progressive.
“The amount of paperwork we had to file was daunting for us, and we’re a family with two working people who have experience working in these systems,” Stewart said. “I can’t imagine for other families who don’t have that experience figuring it out, how daunting this can be. And then you think about how many young people may be trying to navigate these things on their own.”
However, the legislation is controversial, like most legislation across the country concerning transgender individuals.
Anti-trans legislation has been proposed in 43 states this year and signed into law in five states, according to data from LegiScan and Trans Legislation Tracker. Tennessee, Mississippi, Utah, South Dakota and Arkansas have banned gender-affirming care for trans youth, and similar legislation is moving through other states. Several states are looking at eliminating gender-affirming care from their state Medicaid programs or otherwise limit health care access for trans adults.
In the House, opponents of the bill have argued that gender-affirming care should not be provided to children. The bill does not include any restrictions related to age. While the majority Democrat Montgomery County legislation has backed the bill, Kaiser has had to work to convince Republicans and some Democrats in other parts of the state that this health care is necessary.
During a hearing Friday, two delegates proposed amendments that would’ve limited the scope of the bill, but both failed.
Del. Mark Fisher (R-Calvert County) proposed an amendment that would have barred gender-affirming care from being provided to anyone younger than 18. He argued that minors should not be able to undergo surgery related to their gender identity, and said he is concerned about potential effects of puberty blockers. He was opposed to the bill, saying he believes more children identify as trans because of what is being taught in schools. He called the surgeries “child mutilation” and said he’d vote no.
“This is not about health. This is about male-to-female transition and female-to-male transition of children,” Fisher said during the hearing.
Bill sponsors and advocates have argued that it is about health, particularly reducing suicide ideation, and that these medical decisions are only made in consultation with the patient, their medical provider, and their parent if they are a minor.
Fisher’s amendment failed 90-37.
Another amendment, proposed by Del. April Miller (R-Frederick County), would have prohibited gender-affirming care to children without both custodial parents’ consent. If both parents could not come to an agreement on whether their child should transition, the decision would be made in a legal hearing. The amendment failed 91-36.
“These are life-altering treatments,” Miller said. She argued a child cannot make their own decisions because their prefrontal cortex is not developed.
Supporters have said that minors rarely undergo gender-affirming surgeries, and only “under extreme circumstances,” according to Montgomery County-based Del. Bonnie Cullison (D-Dist.19), who served as floor leader during Friday’s debate. Cullison’s district includes parts of Silver Spring, Wheaton, Laytonsville, Derwood and Olney.
Kaiser emphasized the bill was not about children but about adults.
Cullison also argued that many medical providers prescribe additional medications to offset potential negative effects of puberty blockers and hormone therapy.
This legislation has had a long road. Last year, Kaiser introduced a nearly identical bill that received received support from many Democrats. Others didn’t sign on because then-Gov. Larry Hogan (R) said he would veto it. While Kaiser was realistic the bill wouldn’t pass that year, she hoped a hearing including the testimony of trans people could set the stage for a victory in a future year.
But then something unusual happened. The way Kaiser recounts it, the bill essentially disappeared from the docket, even though she hadn’t withdrawn it.
“It’s hard when you’re in the heat of the moment, and you want a bill to pass and you’re working with the community, and you know how much it impacts their lives. Your heart breaks for them,” Kaiser said.
While demoralized, Kaiser said she and advocates used the defeat to come back stronger for the next session. Kaiser said she has been able to garner more support on this bill, she believes primarily because legislators who previously opposed the bill were able to talk to actual trans Marylanders and see a more human side of the debate.
“We’ve been able to change hearts and minds,” Kaiser said. “I asked my fellow legislators to talk to a trans person and to vote with their hearts. People have seen the humanity of trans people.”
The only difference between last year’s bill and this year’s bill is a reporting requirement, which intends to give people information about which gender-affirming care providers are in their network.
Beyond the legislation
Even if the legislation is signed into law, Stewart said there are more barriers that must be addressed by the county government when it comes to accessing gender-affirming care in Montgomery County. One of those barriers is a lack of providers. Stewart said most families she knows with trans children see providers outside the county, who already are overloaded with long waitlists. Her office has requested a report from the county’s Office of Legislative Oversight looking into what services are available to transgender people in the area.
“It’s one thing for us to make statements and say we’re a welcoming community. But how do we actually put that into action and ensure that we are an inclusive community where all members of our community can live and thrive?” Stewart said. “We need to really look at how we can have a role in actually increasing providers and those services for the families and the individuals who need them. And I think that’s very important.”
She recalled having to take time off work to drive to her son’s doctor at Chase Brexton Health Care in Columbia, Howard County to pick up needles and other supplies necessary for his hormone therapy.
“Our family had the ability to do that. But we know not every family does, not every individual who’s transitioning does, so we really need to look at what are the barriers to care right now,” Stewart.
Reynolds-Dominguez said in a time when trans rights are under attack nationwide, it is critical for county leaders to show support for trans residents not only through words, but through actions.
“It’s scary. I live in a blue county but still question if I should have my pride flag out in my front yard, or am I safe shopping at this supermarket?” she said.
Stewart said if Montgomery County wants to truly be a welcoming place for trans people, it must make a change. She pointed to places such as D.C. that have passed trans sanctuary laws. Some cities, counties and states have been working to establish sanctuary areas to shield transgender people and their families, as well as gender-affirming care providers, from potential legal retribution. Sanctuary jurisdictions encourage trans people in states with anti-trans laws to relocate there.
“If we’re going to tell people to come here, we need to make sure we have the care that they can access. If we’re not even able to provide care to the trans people who already live here, we’ve got to be careful about telling people to come here,” Stewart said.
“It’s important to say hate has no place here. But we can’t stop there. We have to follow up words with actions, and continue that drumbeat when the hate is so prevalent,” she said.