# Cost of transition-related care for transgender soldiers deemed ‘negligible’

In a few days our August issue will be out with a story about the implications of the Supreme Court’s King v. Burwell decision on health and health insurance coverage for the LGBT community.

The article by contributing editor Joseph Burns (definitely follow Joe on Twitter  @jburns18) has a sidebar on transgender health issues.

So a perspective piece in this week’s New England Journal of Medicine titled “Caring for Our Transgender Troops—The Negligible Cost of Transition-Related Care” caught my eye.

The Obama administration is preparing to end the ban on transgender people serving in the military, so it makes sense that NEJM would devote some space now to a discussion of the cost of transition-related health care, which can include surgery, hormone treatments, or both.

The author, Aaron Belkin, a political scientist at San Francisco State University who is a visiting professor this year at University of California Hastings College, started the his calculation with this ratio: 0.044 per thousand, or 1 out of 22,727. That’s the claims experience for transition-related health care among large civilian employers, according to a Williams Institute survey.

Today’s military has 2,136,799 troops, so with some simple math (2,136, 799 x .000044) Belkin arrives at an estimate of 94 transgender soldiers seeking transition-related care each year.

But there’s evidence that transgender people are over-represented in the military, writes Belkin:

“…possibly in part because, before attaining self-acceptance, many transgender women (people born biologically male who identify as female) seek to prove themselves that they are not transgender by joining the military and trying to fit into its hypermasculine culture.”

So in his calculations, Belkin doubles 94 to 188.

He uses a cost figure of \$29,929 per year for the care, base on the experience of the University of California system and coverage of transition health.

More simple math: 188 soldiers x \$29,929 = \$5.6 million a year.

If you divide that cost by 12,800, the estimated number of transgender soldiers, it comes out to \$438 per transgender soldier per year

And if you divided it by the total number of soldiers in the military, it comes out to \$2.62 per solider  per year.

Belkin compared his figures to the actual experience in Australia with transgender transition health care, and they were pretty much in the same ballpark.

Of course in many contexts, \$5.6 million is a lot of money.  But Belkin, quite reasonably, sets it in the context of the military’s annual health care budget of \$47.8 billion. From that point of view, \$5.6 million is about a small proportion (about 0.01%) of the military’s annual health care bill.

These are calculations based on assumptions. Time will tell whether the military’s actual experience with transition health care may differ. Belkin notes that military recruiters use health coverage to lure people into signing up. So it’s possible that transition-related care could entice some transgender people to enlist.  However, as civilian employers start to cover transgender health issues, the military’s coverage might be less of a draw. Belkin also notes that transition-related health care and a more acceptance of transgender soldiers in general may reduce some health care costs related to suicide and other problems.