In 2016, Hawaii took a seemingly small but significant step forward for its trans residents: The state passed a law barring insurance companies from discriminating against transgender and nonbinary Hawaii residents. But in the years since the anti-discrimination law, trans residents, advocates and lawmakers found that it hadn't done enough - people were still being denied coverage for care that could help them affirm their gender identity.
On Thursday, Hawaii's Democratic Gov. David Ige signed a bill into law that clarifies certain treatments insurers had deemed "cosmetic" - such as laser hair removal, voice therapy and facial feminization surgery - should be covered as long as a medical provider deems it medically necessary. The legislation, H.B. 2405, would also require insurers to give patients clear information about which gender transition services are covered.
"The bill is key to protecting people from discrimination in accessing gender-affirming treatment," Ige said at a signing ceremony, Honolulu Civil Beat reported. The governor also signed two other bills expanding LGBTQ protections in state: one that bars people from being excluded from juries because of their gender identity and expression, and another establishing a commission that will examine the status of Hawaii's LBGTQ residents.
The health-care bill, which was crafted with input from health-care providers, trans advocates and insurers, passed with overwhelming support in both chambers of Hawaii's legislature. The law went into effect immediately on Thursday.
The issue highlights how difficult it is for transgender and nonbinary people to access medically necessary and potentially lifesaving gender-affirming health care, even in areas that embrace and support them, said Democratic Hawaii state Rep. Aaron Ling Johanson, a champion of the bill and chair of the state's Consumer Protection and Commerce Committee.
Johanson said the policy change had been a "passion project" for him.
"One of the things that we came to find was that . . . 'cosmetic' treatments are a very critical part of accomplishing gender-affirming care for the patient," Johanson said. But "clashes" persisted between trans and nonbinary Hawaii residents and insurance companies, he said, because some insurers decided the care was not medically necessary, even if a patient's medical provider had recommended it. (Hawaii Medical Service Association, the state's largest insurer, declined to comment.)
"It's just heartbreaking when you hear from a lot of these folks who have higher rates of depression or thoughts of suicide because they're just stuck in a system that doesn't help them," Johanson added.
Fan Liang, medical director of the Johns Hopkins Center for Transgender Health, said that for trans and nonbinary patients, there tends to be more coverage for "top" and "bottom" surgeries (chest and genital surgeries), but not for procedures such as facial or voice surgeries. That's a big oversight, Liang said, considering how important these characteristics are in everyday life.
"When you engage with somebody, the first thing that they appreciate, really, is your face and facial expressions," Liang said, adding that many of her patients have told her stories of being misgendered over the phone. Some worry their voice is "a telltale giveaway" of their transition.
Generally, Liang said, gender-affirming care, which includes psychosocial and educational resources as well as medical interventions, helps trans and nonbinary people live more freely, whether that's relieving their gender dysphoria or reducing the likelihood they'll be singled out or discriminated against.
"It really is a medical necessity," Liang said. "These patients are living with an incongruence that permeates all aspects of their lives."
In passing its new gender-affirming care bill, Hawaii has joined a handful of states, including Washington and Colorado, that have tried to expand access to transition care.