“It's frustrating to me, as a healthcare provider that I have an ethical and legal obligation to provide an evidence based practice, but our legislators have no obligation to practice evidence-based legislation. If we had evidence-based legislation, we would providing healthcare to everybody,” says Full Spectrum Health physician Dr. Tracey Wiese. “We would be providing more wellness care.”
In a time when affordable healthcare is a topic constantly being discussed and debated, the providers are often stuck in a position of their desire to provide for their patients and the need to be paid for the services that they provide.
Wiese continues, “We know from research that those things work, but we have interests from big pharmaceutical companies. It's not beneficial to pay more for massage, when they can keep you on Zoloft. I provide medicine for a living, but it's a racket. If we had evidence-based policy making we would have equitable healthcare. There is so much evidence that shows it is the right way to do it, and it shows that wellness care is the right way to approach it.”
Wiese opened Full Spectrum Health Clinic in midtown this past summer and while her and her staff provide services for any that come to them, they specialize in the needs of the LGBTQI+ community, and even more specifically, their transgender patients. A person who is transgender may never decide to have any of the procedures, surgeries, or treatments that are considered gender affirming healthcare, but for those that do, it is not always covered by insurance, and can be extremely expensive if paid for out of pocket. Here is a breakdown of the cost of what one person could expect to pay in order to have just some of them:
Hormone Therapy: $1,500 per Year
Gender Reassignment Surgery: $30,000-Plus
Facial Feminization Surgery: $25,000-$60,000
Breast Augmentation: $5,000-$10,000
The figures stated above do not reflect the cost of other things such as counseling, electrolysis, or even the new wardrobe that most end up needing; not to mention things like binders, makeup, and court costs for legal name change. At the same time, while Alaska has protections in place for discrimination, there is still discrimination. Wiese has clients that have told her of instances where they have lost jobs, been denied employment, or have lost housing.
This lack of balance is at the center of the change that Wiese believes will be occurring within the system. “Premium costs are rising, procedure costs are rising, drug costs are rising, and benefits are lowering. I really do think we are on a tipping point. I think in the next 5 years we are going to see a drastic change in the way the Americans access healthcare. The current system is not sustainable. We may be moving to a single-payer system, or a pay-for-outcome-type system. I think there are going to be a lot of changes. The current system is not working, and it's disproportionately not working for women, for children in poverty, especially children of color in poverty. It's disproportionately not working for communities with higher numbers of people of color.”
In Juneau, it has been reported that 36-year-old Jennifer Fletcher is currently suing the state of Alaska because her AlaskaCare health plan does not cover gender-affirming surgery. Fletcher has been diagnosed with gender dysphoria, a term for someone whose gender identity does not match their biological sex. The U.S. Equal Opportunity Commission has determined that there is reasonable cause for the lawsuit, and that opened the door for Lambda Legal, a 501c3 organization that is dedicated to achieving full recognition of the civil rights for the LGBTQI+ community.
This is a struggle that Wiese knows well, considering that the majority of her client load have Medicaid, and in Alaska if a claim is coded with F64.9, the billing code for gender dysphoria, the claim will be thrown out. Wiese says, “There are states that are providing these services in a cost effective way. It's not costing the state more money. Research shows that the long term outcome, especially when we can transition people earlier, we are actually saving money in disability, mental health costs, in physical health costs. When people are affirmed and happy, they are well. Well people don't cost us as much money, Insurance companies always lag behind science. Even if the guidelines say informed consent.”
There are some non-profits set up in order to help defray some of these costs for people, and there are surgeons who have been known to provide one surgery a year for free. Even Wiese is willing to work with some of her clients, but it does make things harder on her. With Medicaid refusing to pay for some of the necessary treatment, and Wiese's decision to allow some people to work on payment plans, things can get very tight around Full Spectrum. The other challenge that she faces is that as a Nurse Practitioner she is automatically paid 20 percent less than a doctor when she is providing the exact same service and writing the exact same prescriptions. “Premium costs are going up, reimbursements are going down, health care is getting more expensive, but what providers are getting paid is drastically dropping,” Wiese said. “Meanwhile, everything is becoming technology-based, so it costs $1,200 a month just to chart and send claims electronically, which they are now required to do. I have to hire more than one provider so that I can keep my doors open, maintain malpractice insurance, and yet still I am making 20 percent less.”
For now, the cost of gender-affirming healthcare is troublesome, and the legislation in place does not always recognize that care as necessary. We are getting to a point where this will not always be the case. Until then, dedicated providers will continue to fight the rising costs while trying to care for their patients. For Wiese, she believes that change is coming, and change is necessary, so she will keep doing her best.