And it’s not a zero-sum game. Whether I have health insurance shouldn’t be contingent on whether some murdering lunatic also has healthcare.

It shouldn’t be a zero sum game. But in the context of a prison’s budget, if they have X amount of dollars budgeted for health care, how much would this surgery cost, and what might be the trade off? A court order that orders this treatment, without finding funding, might mean that the prison has to dip deeply into medical funds for this one treatment at the expense of a lot of other prisoners.

Medically necessary/unnecessary isn’t a binary definition. There are the things where you need immediate treatment or you’ll die, the things where you need immediate treatment or you’ll be permanently injured/crippled, the things where you need reasonably prompt treatment to avoid long term consequences, etc. A continuum. This falls somewhere between, say, surgery for a ruptured appendix (surgery now or your dead in less than a week) and non-reconstructive elective plastic surgery (may improve quality of life, but no significant consequences for not getting it done in most cases.) Exactly where, I’m not sure.

Whether a prison budget should cover this depends in part, I think, on how well the budget is covering other medical needs. We know prison budgets are stretched just to meet the immediate life-and-death problems. If it’s a trade off between this and other care of the same urgency, that’s one thing. If covering this cuts into care for significantly more urgent conditions, it’s not as reasonable to make the trade.

The state’s spent an awful lot of money fighting this. If there was some way to look ahead to the money spent for legal costs fighting “unnecessary” treatments and transfer it to health care, it would be ideal. On the other hand, if they spend dollars budgeted for medical care in prisons on things like this without suitably increasing the budget, it may become more of a situation where something potentially high profile and dramatic gets the attention, in order to avoid controversy and the press, while routine but perhaps more urgent needs are neglected.

Universal health care in Canada is not state controlled.

Someone is always, in any system, making decisions about what procedures, under which conditions, qualify for coverage. In the United States, our health care is controlled by insurance companies (subject to state and federal law) and by doctors, if you can pay out-of-pocket. In a single-payer system, the single payer controls what they’ll pay for. If you don’t like their decisions about what is covered, then you’re either (1) out of luck, or (2) potentially able to lobby the government to change the policy. If you don’t like what your insurance company decides they’ll cover, you can (1) switch insurance companies, if you are able to get coverage elsewhere; (2) lobby the company, either through their appeals process or through public relations pressure; or (3) lobby the government to change the laws relating to insurance coverage.

The heart of the issue is exactly what nexyjo said:

this discussion, i think, boils down to how we define “medically necessary”, and who gets to make that decision.

With transgenderism, there’s so much bigotry and misinformation out there already, I think we do well to consider whether we’d rather have the decisionmakers be the federal government or a multitude of individual insurance companies (in the context of universal coverage, of course). Neither one is totally palatable, but I think there’s an argument to be made that at least with a bunch of insurance companies, you’d probably have at least a few start popping up that would offer services to transpeople, particularly if you had high-profile advocacy groups (e.g., HRC, NOW) start to apply pressure. As has been pointed out time and again, insurance companies are largely amoral, and that may be a good thing if the alternative is the “family values” morality that keeps getting voted into Congress.

most (some estimate 90%) never have a “sex change operation”.

I’d be interested in seeing where a statistic like that comes from. Thing is, no matter what we call it, there isn’t one surgery for either mtf folks or ftm folks that could be considered “the sex change operation”. Not to get gory or overly detailed, but some states require lower/genital surgery to get birth certificates changed, some seem satisfied with chest reconstruction for ftms (if it’s called “irreversible sex reassignment surgery” or something), some seem more interested in reproductive sterility via surgery…some won’t change a birth certificate for anything. I know the birth certificate correction isn’t the be-all end-all, but it’s some sort of measure.

Even genital surgeries…for trans women there seems to be a standard procedure that varies by surgeon….for trans men there’s at least 3-4 separate types of sex reassigning genital reconstuction.

Am I getting off topic?
I also think cost is a huge barrier in those that have to pay out of pocket. Clearly.

Yet another facet to just the trans health portions of this…would out of country surgeries be covered? Because from my perspective, the best genital surgeries for trans men are currently evolving in Europe.

there are no such tests for the degree of transness from which an individual suffers.

Admittedly, this is sort of a doozy. There are no objective tests because being trans is an entirely subjective experience, as you point out.

That being said, how does one draw that line? Do we use a pain scale? Subjectively assigning numbers as medical diagnosis works there. Are only people (for example) who suffer at 7 or up to be covered? 6s just need to suffer at 6 and if only they hurt a little tiny bit more they’d be eligible?

Rather than even try for that sort of test, ‘twould be easier to simply allow the patient and doctor to make the decision. I’d also say the same about your hip replacement scenario; if the doctor and patient agree that it’s for the best… who is anyone else to judge?

And in this perfect world where American transpeople have relevant health insurance, I’d also like a pony.

in a case where someone has a bleeding open wound, i think most (if not all) of us would agree that it is a medical necessity that the wound get stitched up, the bleeding gets stopped, and that pain relievers, if necessary (there’s that word again) are administered.

many medcial conditions are not so clear.

the therapist who treated me during transition likened the medical necessity of transition for someone like me to someone with osteoarthritis who requires arthroplasty (hip replacement surgery). in this kind of medical condition, arthroplasty is indicated when their pain and decreased mobility “interferes with daily activities despite treatment”.

i’d argue that the degree of immobility and pain that cause an interference with daily activity is contextual. is someone in prison faced with the same interference in their daily activities when suffering from gender identity disorder (or whatever they’re calling it these days) as someone on the outside? at what level is pain considered an interference with daily activities? and how do we measure the level at which the interference of daily activites indicate treatment?

in the case of hip replacement, i’d argue that if ones pain prevents them from getting out of bed and using the restroom, then replacement is indicated. or if they are unable to get into their car and get to work. are the same parameters valid in the context of prison? and if the arguement is that prison is gendered, would moving trans inmates from gendered space be enough?

the degree of evaluation experience with hip replacement is rather common when compared with gender identity disorder. part of the problem, i believe, is that transgender people span a wide range of symptoms and treatments. most (some estimate 90%) never have a “sex change operation”. many never have electrolysis. and some never use hormones. these treatments are most often “prescribed” based on the aflicted individual’s self assessment. there are very few physical tests to offer as evidence that these treatements are necessary, unlike hip replacement. a crumbling bone, visible in an x-ray, does wonders for “proving” that surgery is necessary.

there are no such tests for the degree of transness from which an individual suffers.

Universal health care in Canada is not state controlled.

Exactly. If only most of my fellow Americans weren’t so ignorant about universal heath care. That’s at least part of the health care problem in America. Sad but true. the majority really believe ‘universal health care’ means poor care by second-rate doctors which will cost you a lot of tax money and which is available only on an on and off basis (because of waiting lists). Yeah yeah I know, it’s kinda off the topic. But that sort of ignorance makes me so fucking angry.

What we have is a [i]single payer[/i] system. The single payer being the government, of course.

You know how employers can get lower prices from insurance companies because they are insuring a lot of people? Well, we get a better rate because we’re insuring the whole damn country. (In essence, anyway.)

We’ve got public auto insurance in some provinces too – helps keep insurance rates and profits at a reasonable level. Plus, the insurance profits get plowed back into services – like funding seatbelt or anti-drunk driving education. (Or, in election years, refunds to automobile owners.)

We need a universal health care system if we intend to remain a major player on the world stage; to allay our slow, agonising slide into despotism.