The Pandemic Sparked a Revolution in Trans Care. Washington May Let it Fade Away

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When the Covid-19 pandemic reached US shores roughly three years ago this month, it changed everything, including how we handled the medical needs of those who were lucky enough to not have caught Covid-19. Policymakers in Washington didn’t know a lot at that point but they had more than a hunch that it was in everyone’s best interest to keep patients who weren’t battling Covid-19 from sharing the same waiting rooms as those who were, especially if the reason they were meeting with their health care providers was as simple as a prescription renewal, a check-in about an ongoing treatment regimen, or even a physical therapy session that could be done with some props already found in the pantry like canned goods.

So began a golden age of telemedicine, a coinage that carries decidedly mixed verdicts depending on where the user sits on the political spectrum. Medicare moved to allow virtual or even telephonic doctor visits to keep non-Covid patients away from waiting rooms. Private coverage mirrored that approach without much cajoling from Washington. Many quickly saw the benefits in the break from tradition, as privacy requirements were waived to allow doctors to use platforms like Zoom and email to connect with patients from afar. What had previously been a footnote entrypoint for care suddenly surged; in California, for example, Medicare beneficiaries using telehealth leapt from 3% pre-pandemic to 41% a year later, according to one government study. While the overall participation rate has dropped since vaccines came along, in areas like mental health and addiction counseling, the numbers have held solid in the 40s.

And perhaps no segment of the health space changed more quickly—and quietly—amid the pandemic than that of gender-affirming care for transgender patients. Thanks to temporary changes that allow federal health payments to operate on a virtual plane—and with private health providers largely following that lead, it is now totally normal and common for hormone replacement prescriptions, counseling, and even hair-replacement treatments to operate completely outside brick-and-mortar doctor offices. But those flexibilities are set to start to contract as early as May, and the end of 2024 could bring an even bigger snapback for a whole host of accommodations.

“Telehealth in some way is going to be a staple with pretty much every healthcare organization that there is,” says Dr. Jerrica Kirkley, the chief medical officer and co-founder of Plume, the nation’s largest and leading telehealth practice for gender-affirming health care. “It’s here to stay in a big way, especially with our community.” But the path forward gets tougher if the federal government doesn’t recognize that some of the policies it put in place because of Covid were a vast improvement over what we were all doing before.

Plume began before the pandemic roiled so much of Americans’ relationship with health providers, although even before Covid, an overwhelming majority of trans patients said they much preferred a telehealth option for accessing gender-affirming care. The trans experience already carried significant emotional roadblocks well beyond insurance forms; being deadnamed, misgendered, and harassed is far more common than you’d think, even in the best-trained and professed inclusive settings. Using platforms like Plume, which was founded by trans individuals for trans individuals, can make a difficult process less traumatic so patients can focus on care rather than meeting cultural expectations in a world where more than a dozen states are actively working on making life harder on trans teens.

But—as is the case with so much of Washington—nothing here is certain to survive, even if it’s good policy. The White House has declared the public-health emergency for COVID-19 will end on May 11. Among the changes coming with that moment will be the end of a waiver of a Drug Enforcement Agency rule requiring controlled substances—including hormones like estrogen and testosterone as well as allergy pills, blood pressure and cholesterol correctives, and anti-inflammatories—to be prescribed only with in-person consultations. So without some tinkering to the 2008 Ryan Haight Act, which was written to curb online pharmacies, patients who started hormone-replacement theory from afar will need to find an in-person session to get their next Rx script.

Of course, transgender patients won’t be the only ones affected. If you started pretty much any prescription drug in the last three years, you’re going to have to make a visit to your doctor in the coming months to keep taking it unless Washington addresses this looming crisis before then.

“That could mean things could change in a big way for a lot of folks,” says Kirkley, who expressed optimism that the Biden administration would find a way to continue a policy that has been a gamechanger for so many in the trans community. “We’ve seen such a massive benefit in terms of access to care that I do think there’s enough momentum.”

But nothing is guaranteed, even inside an administration that acknowledges it has a deadline that is coming quick.

In other corners of the policy world, things are a little less immediately grim. As part of a massive spending bill that Congress passed and Joe Biden signed late last year, Medicare-covered telehealth appointments can continue until the end of 2024 without too many interruptions, although Medicare fees are set to be curbed as part of the paired policy. Because of the expanded access and use in recent years, spending on Medicare programs is up, which helps fiscal conservatives’ argue against making these health-from-anywhere platforms permanent.

Still, if it feels like Washington is kicking the can on yet another question, you’re right. The health care industry made rapid investments in telehealth platforms during the pandemic but doesn’t have a ton of clarity about what comes next, both immediately after the end of the health emergency in May and then again next year, when Medicare coverage of Zoom’d check-ins may lapse. These questions are known and the answers are largely obvious if the only test is if access to care is the goal. Even the costs are hardly the most obscene in the federal budget. But Washington isn’t one to take action until something is urgent, meaning plenty of players in this space—tech, medicine, even real estate firms that own the offices for doctors—are going to be lobbying for their own interests with some intensity, likely until the last possible minute. And, of course, that leaves patients as secondary worries for D.C.

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