How Navigators Influence Insurance Coverage for Gender-Affirming Surgeries: A Qualitative Study

Introduction The passage of the Affordable Care Act improved access to gender-affirming care but positioned insurers as the primary gatekeepers of treatment. Insurers have developed criteria for coverage approval that result in barriers to care for some individuals. In this study, the author sought to understand the experiences of individuals seeking insurance coverage for gender-affirming top surgery. This report summarizes the role of navigators in facilitating access to coverage. Methods This study is based on semistructured, in-depth interviews with 30 transgender and gender diverse people assigned female at birth. The participants were diverse in age, race and ethnicity, geographic location, type of insurance coverage, and care setting. Thematic analysis was used to examine key influences on the coverage-seeking process. Results Participants identified navigation as a key domain. Analysis centered on 3 themes: navigators improving access to care; the contribution of lesbian, gay, bisexual, transgender, queer plus (LGBTQ+) health centers in facilitating access; and the role of informal navigators in furthering the inequitable distribution of care. Participants reported that navigators improved the likelihood of insurance coverage for gender-affirming surgeries and reduced health care inequities based on sociodemographic characteristics. Conclusion Nonstandardized criteria among insurers promote inequitable access to health care because approval relies on consumer ability to navigate complex systems and adequate economic resources to fulfill criteria. Improved access to navigators would reduce barriers to gender-affirming care.