For decades, insurers have denied coverage for procedures to help people transition. For many of them, becoming who they truly are is worth fighting over what is “medically necessary.”

For Dana Ann Wallingford, gender reassignment surgery could mean the difference between self-acceptance and waking up every morning disgusted with her body.

Surgery for the 60-year-old transgender woman is “medically necessary” to her emotional health, she says, yet her insurance company doesn’t see it that way.

For decades, transgender people have been denied coverage for surgeries, mental-health therapy, hair removal and medications that would help them transition to another gender — anything related to transgender health care was excluded in insurance plans. Despite major strides for trans people in the last two years, many insurance companies and state government plans that no longer categorically exclude all transgender care still exclude some transition-related procedures, often calling them “cosmetic.”

Wallingford, who wears her wavy, graying hair to her shoulders and easily “passes” as a woman, worries she is running out of time to find peace with her male anatomy.

“Every time I get out of the shower and I look at myself in the mirror, I think, ‘That’s not want I want,’” she said. “It’s a big deal every day. I feel like, with this body I have, I can’t imagine being in a relationship with someone.”

Wallingford began taking hormones a few years ago after repressing feelings that she was a woman most of her life. She has Medicaid insurance, which covers hormones but not gender reassignment surgery.

At least not yet.

Colorado this fall began holding public hearings on proposed policy to cover transgender-related surgeries for people with Medicaid, government-sponsored insurance for needy and disabled Coloradans. The next hearing, scheduled for Feb. 16, will focus on transition-related surgeries. The process could take more than a year.

Medical guidelines regarding transgender care have changed in the last few years, with the American Medical Association and the American Psychological Association saying hormones and surgeries are the recommended course for patients with gender dysphoria.

Transgender health care

A survey of transgender people published in 2011 found that about 20 percent were uninsured. Below is a breakdown of their insurance type and where they got care.

Michelle Doe, The Denver PostSource: Injustice at Every Turn: National Transgender Discrimination Survey

Note: The study includes 6,450 respondents and transgender and gender non-conforming participants

Times have changed and the state Medicaid program “has a responsibility” to evolve, said Judy Zerzan, chief medical officer for the state agency that runs the Medicaid program in Colorado.

“The world and the evidence and the practice of medicine evolve,” Zerzan said. “We think we have a responsibility to cover it when it’s medically necessary.”

The federal government prohibited Medicare and Medicaid from covering transgender-related surgery until 2014. The ban was lifted for Medicare, which provides health insurance for older Americans, but there was no universal policy change for Medicaid, which is administered by states.

Eight states changed policy in recent months to cover transition-related surgeries, but Colorado was not among them. An ongoing federal review requested by the Obama administration this fall could trump Colorado’s process if it requires all 50 states to cover transgender-related surgeries through Medicaid.

In September, the administration proposed a new anti-discrimination provision that could require doctors and hospitals to allow patients to use the bathroom of their gender identity as well as bar insurance companies from excluding transgender surgeries and therapy. The Affordable Care Act prohibits sex discrimination, but new rules would clarify that gender identity also is protected.

Colorado is among 13 states that prohibit insurance companies from blanket exclusions against transgender-related care, but the law does not mandate coverage of gender reassignment surgeries. The state Division of Insurance in 2013 said companies cannot charge transgender people higher premiums, consider transgender status a pre-existing condition to deny coverage or limit coverage for “medically necessary services” if the same service or surgery is provided to someone who is not transgender.

That means if a company covers hormone replacement therapy for other reasons, it should cover it for transgender people. But the law gets opaque regarding surgeries. If an insurer covers mastectomies for breast cancer patients, does it have to cover them for transgender people who want their breasts removed or augmented? And if a company covers a hysterectomy or genital surgery for a car accident victim or someone born with a genital anomaly, must it cover that for a transgender person?

“That’s where we are kind of stuck at this point,” said Matt Mortier, the insurance division’s director of compliance. “We would like some more concrete federal guidance.”

Out-of-pocket costs

Mal Foust, a paramedic at University of Colorado Hospital who transitioned to male about two years ago, spent $10,000 for “top surgery” because his insurance plan considered a double mastectomy for trans men a cosmetic procedure. Foust, 29, was able to raise about $4,500 through donations from friends. He just finished paying off his credit card balance for the August surgery.

The expense and the trip to Florida for the surgery were worth it, Foust said.

Transgender therapy and surgeries

Transgender people who participated in the 2011 survey reported high rates of treatment with hormone therapy, and varying rates of treatment for gender-transitioning surgeries.

Michelle Doe, The Denver PostSource: Injustice at Every Turn: National Transgender Discrimination Survey

Note: The study includes 6,450 respondents and transgender and gender non-conforming participants

“At this point, I’m finally feeling like myself for the first time in my life,” he said. “I have a confidence that I didn’t know I had.”

Before surgery, Foust wore a binder — a garment like a sports bra to flatten the chest — that was so tight it caused back pain. He couldn’t wear it to work out, which made him feel awkward at the gym. Now he’s looking forward to taking off his shirt during an upcoming trip to the beach.

“I am fulfilled,” he said.

For some trans people, dressing in different clothes and changing hairstyles is enough to transition. A majority want hormones, but many choose not to change their bodies through surgery.

“It’s really between a doctor and a patient,” said Michael Silverman, executive director of the New York-based Transgender Legal Defense & Education Fund.

Colorado and other states that passed anti-discrimination laws for commercial insurance companies “have good intentions, but not enough enforcement,” he said. His organization, which files lawsuits on behalf of transgender people facing discrimination, is representing a transgender Colorado woman denied coverage for gender reassignment surgery by Aetna Life.

Before the 2000s, almost any request related to a person’s gender identity was denied. Some denials bordered on absurd — a patient’s heart problems were related to the stress of being transgender and therefor denied, said Harper Jean Tobin, policy director for the National Center for Transgender Equality. Although progress has been made, problems persist. Transgender men, including Foust, keep their gender marker “female” on insurance documents so they are not denied coverage for gynecological exams.

Studies, including one from Johns Hopkins University, have found that denying coverage for transgender-related health care has led to increased mental-health problems, poorer overall health and financial distress.

“It really does make a difference between tremendous suffering and being able to be a healthier and productive member of your family, your workplace, your community,” Tobin said.

Counties cover surgeries

Summit County commissioners voted this week to cover gender-reassignment surgeries for transgender county employee or family members. Denver city and county employees received that benefit in 2014.

“In the 21st century, this is what being an equal-opportunity employer will mean,” said Thomas Davidson, one of Summit County’s three commissioners.

None of the county’s 900 employees and dependents had previously asked for gender reassignment or other transition surgeries, which typically cost about $100,000 to $150,000 over two or three years.

At Denver Health Medical Center, staff in April will begin using a new records system that for the first time will log a person’s gender identity status and preferred name. A flag on a transgender person’s file will remind staff to greet the patient with the correct name and pronoun, as well as alert doctors that the person might need medical tests related to their birth gender, said Paige Jackson, an LGBTQ patient navigator for the hospital.

Jackson, who is transgender, recalled her own humiliation at another hospital when doctors performing her appendectomy kept calling her “him” and “he” despite that she was dressed in female clothes and wearing jewelry. “It was dehumanizing,” she said. “It was like, ‘Don’t you see who I am?’”

Kaiser Permanente Colorado began covering gender reassignment surgery in 2014. The company also covers mastectomies for people transitioning to male, but other procedures — including facial feminization surgery and breast augmentation — are still considered cosmetic.

Kaiser will pay a portion of travel expenses to send a patient to California for gender reassignment surgery because there are no Colorado surgeons who do the operation, said Jandel Allen-Davis, vice president of government, external relations and research.

The hope is that evolution in insurance coverage will lead to more Colorado surgeons performing transition-related surgeries, said Laura “Pinky” Reinsch, political director for One Colorado, which found about half of companies in the state cover transgender care.

Without access, transgender people will risk their health to become who “they are supposed to be,” said Lyndsey DeFeo, who transitioned five years ago at age 32. DeFeo bought testosterone blockers and estrogen online, with no doctor to monitor her hormone levels.

“I’m not myself without it. I’m not who I am supposed to be,” DeFeo said. “It took me a long time to figure that out but once I realized that I was really a woman, I needed to do that.”