Yourself comes at a high price
It’s her oestrogen. And, because she’s transgender, it is expensive.
Morris has medical aid but most schemes don’t cover gender-affirming treatments such as HRT.
Bhekisisa surveyed six of the country’s largest medical schemes: the Government Employees Medical Scheme (Gems), Fedhealth, Discovery Health, Momentum Health, Bonitas and Profmed. Together, these schemes are responsible for more than three-million people — or almost a third of all privately insured South Africans, according to the Council for Medical Schemes’ latest annual report.
Momentum Health and Bonitas declined to comment. But the survey found that Gems, Fedhealth and Profmed require members on HRT to pay for the chronic medication out of their medical savings and when that is exhausted, eventually, their pockets.
Discovery Health is running a pilot programme that pays for surgery as well as hormonal treatment. So far it has approved care for two out of the five patients who applied to be part of the programme.
In the past, Morris tried to use her medical aid savings to pay for her HRT — but her scheme wouldn’t always pay up. Today, she spends about R800 a month from her own pocket for the daily tablets. If she
Review Journal, the same after receiving this type of care.
To try to ensure that people in need of chronic medication don’t go without, the law prescribes that 25 lifelong conditions such as asthma, diabetes and hypertension must be covered in full by medical aids. Illnesses such as these form part of what is known as prescribed minimum benefits (PMBs), which also include emergency care, mental illnesses and heart disease.
On the road to a National Health Insurance, the recently released Medical Schemes Amendment Bill proposes scrapping PMBs in favour of a more comprehensive package of conditions and services. But it’s unclear what conditions would be included.
Right now, however, genderaffirming treatment — vital and sometimes lifelong as it is — isn’t a PMB.
Why not? The answer may say more about society than it does about medicine, University of Cape Town clinical social work lecturer Ronald Addinall says.
“Historically, private medical aids classified gender-affirming interventions such as hormoneaffirming treatment and genderaffirming surgeries as ‘lifestyle’
choices and not as quality of life priorities,” he explains. Addinall also works with the LGBTI rights organisation, Triangle Project.
But surgeon Kevin Adams argues that medical aids should be covering this type of care. Based in Cape Town, Adams specialises in gender-affirming surgery and says he advises patients to check whether procedures are covered by their medical aid before going ahead.
If doctors have cleared a patient for surgery and a medical aid refuses to pay, then patients should seek legal advice, he says.
Legally, medical aids that don’t cover such treatment may be violating trans people’s constitutional rights, Legal Resource Centre attorney Mandy Mudarikwa argues.
“Section 9 of the Constitution prohibits discrimination, among others, on the grounds of gender.
“The blanket exclusion of all gender-affirming care in the PMBs is contrary to the Constitution, specifically the rights to equality, dignity and access to healthcare among others,” she says.
But, she says, the crux is that many medical aids continue to believe that gender-affirming treatment is a choice, rather than a health need.
“Schemes often categorise surgeries as cosmetic. Yet equality is both a value and a right in South Africa.”
But the fate of trans people could change. The head of healthcare and life sciences at Werkmans Attorneys, Neil Kirby, says patient groups can lobby the Council for Medical Schemes to amend the Medical Aids Act on socioeconomic grounds, arguing that the cost of gender-affirming treatment is too high and compromises the right to health enshrined in Section 27 of the Constitution.
Morris is hoping to collect the evidence needed to make such a demand.
For the past 16 months, she has been gathering information on what kind of transgender care medical aids cover and under what plans. She wants to use the data to show the Council for Medical Schemes just how far away South Africa is from upholding international guidelines
on transgender healthcare — and hopefully change legislation to fix this.
Discovery Health is already rethinking its benefits. For more than a year the scheme has been piloting changes to the way it funds transgender care, providing both surgery and HRT to some members. But there’s a catch.
To qualify for the pilot, people must have been a member of the scheme’s executive or comprehensive plans — among Discovery’s most expensive options — for at least three years, Noluthando Nematswerani, Discovery Health’s head of clinical policy says.
But a member of the executive plan pays almost R6 000 a month in premiums.
Morris argues that this is unaffordable for most people and that members of those schemes are already likely to be able to pay for treatment out of their own pockets.
Meanwhile, Morris is a step closer to reaching her goal. After negotiations with Discovery Health and threats to take them to the Council for Medical Schemes, they’ve agreed to pay for her HRT.
“But they are going to have to process the claims manually because their system will reject it,” she explains.
“I want medical aids to play fair according to the Constitution, and implement fair support for trans surgery, which is life-affirming and often life-saving.”