When the Hawaii Legislature’s session kicked off in January, members of the state’s transgender community and their advocates were hopeful they could get proposals passed making it easier to get medical procedures related to gender transition covered by health insurance.

But as the legislative session winds down, it’s looking increasingly unlikely that those measures will pass.

The House has just one more day — Thursday — to hold a hearing for a concurrent resolution that would express the Legislature’s support for “gender transition treatments and services as medically necessary for the purposes of health insurance coverage,” according to the original draft of the proposal.

A bill with a similar message died earlier in the session. Instead, the Hawaii Senate passed a resolution on its own asking the auditor to look into the issue.

The state insurance commissioner testified that an audit would be necessary before insurance mandates could be expanded, but advocates for Hawaii’s transgender community argued that an audit doesn’t go far enough.

Hawaii passed a law in 2016 to “prohibit the denial, exclusion, or limitation of health care services or treatment to a person on the basis of a person’s actual gender identity or perceived gender identity.”

That means Hawaii insurance companies can’t discriminate against someone for being transgender, and in practice, insurance companies cover medications such as hormones and certain gender reassignment surgeries such as orchiectomies.

Jen Jenkins, community co-chair to the Sexual and Gender Minority Workgroup, said they want the Legislature to clarify the law to make clear that all transition services are medically necessary for the purposes of insurance coverage.

A previous version of this story incorrectly said Jenkins worked at the ACLU.

“Trans people in Hawaii aren’t getting the health care that they’re guaranteed to by law,” Jenkins said.

Jenkins is backing the original version of Senate Concurrent Resolution 161 after House Bill 285 died earlier this session. Rep. Mark Nakashima told Civil Beat he declined to hear the measure after the Hawaii Medical Service Association told him that it wasn’t necessary.

“My understanding from the insurance companies is that they don’t deny any procedure on the basis of gender identity. The one exception to that is what they consider cosmetic surgery like breast implants, which may be necessary for someone who is transitioning to a woman, but at the moment they consider that cosmetic,” he said. “If it was considered cosmetic, I didn’t question it.”

That’s disappointing to Camara Miyamoto, director of the LGBTQ center at the University of Hawaii at Manoa, who called the bill “absolutely critical.”

“It’s a matter of life and death,” he said.

An $8,000 Loan

That’s how Breanna Zoey Connors feels. On Tuesday, the 37-year-old trans woman underwent breast augmentation surgery in Honolulu. Connors doesn’t expect that her insurance, HMSA, will cover the procedure. Instead, she took out an $8,000 loan from her 401(k) to pay out-of-pocket.

She said insurance covers some procedures related to her transition, such as a vaginoplasty, but she expects to pay $20,000 to $40,000 out-of-pocket for facial surgery and isn’t yet sure where the money will come from. But going into debt is worth it, she says, because of the mental anguish of being constantly misgendered.

“It’s just so traumatic,” she said, “not being able to have the world see you as you are.”

She’s been plagued by depression and anxiety that’s been exacerbated by the financial stress of the procedures. In February, she felt suicidal at the thought of the high costs.

“I’m very thankful I’m still here today,” she said.

Stefanie Park, assistant vice president of medical management at HMSA, told Civil Beat that the company approves gender transition services such as psychotherapy and gender confirmation surgery “as long as they’re considered medically necessary” per its policy.

“Other surgical procedures which can be considered cosmetic in nature must be reviewed on a case-by-case basis for medical necessity,” she said. “Cosmetic services that do not restore or materially improve a physical function are ineligible for coverage for all of our members regardless of gender or gender identity.”

A spokeswoman for Kaiser referred Civil Beat to the company’s policy, which includes “behavioral health assessments and counseling, hormone therapy, and gender affirming surgeries.”

“Kaiser supports culturally competent care to all of its patients, and supports parity in coverage without discriminating on any protected basis,” the company wrote in its public testimony on House Bill 285.

Both companies supported the idea of an impact assessment audit prior to approving a mandate, according to their public testimony.

Broader Issue

Compared with other states, Hawaii is considered a relatively LGBTQ-friendly state in terms of state laws, in part because of the 2016 law to ensure insurance companies don’t discriminate against transgender people, introduced by Sen. Chris Lee.

“The intent was to make sure that people’s gender identity and everything associated with it is covered because it’s a core part of who people are and how they’re perceived in society,” Lee told Civil Beat. He said he expects that in some cases, breast augmentation would be covered.

Rodrigo Heng-Lehtinen, deputy executive director at the National Center for Transgender Equality, said it’s common for transgender people to have to fight to get procedures covered even with the existence of non-discrimination laws.

He noted the insurance company Aetna recently announced it would cover breast augmentation for transgender people and believes the industry is headed in that direction.

“I think some insurance companies are going to get there kicking and screaming,” he said. “It is eventually going to happen because it is considered essential care.”

Laura Edwards-Leeper is a psychologist and professor at Pacific University who has worked with transgender youth and adults for many years. She said from her perspective, insurance coverage for medical interventions for transgender people is critical for their mental and physical health.

“For trans females who have gone through male puberty and have all of the masculinizing effects of testosterone, it can be very, very hard for them to ‘blend in’ as a woman if that’s their goal,” she said. “A lot of them have very permanent effects from male puberty. It puts them literally in danger because they are then targeted by people who engage in hate crimes.”

She said insurance coverage is hugely important not only so that transgender people who need the procedures can feel better but also so they aren’t getting targeted for appearing transgender.

“It’s very different than cosmetic surgery for cisgender people who just want bigger boobs,” she said. “We’re talking about helping them live comfortably in society so they can be perceived correctly and live a happy life like everybody wants to. The surgeries are very expensive and so very few people can afford that out of pocket.”