Last Tuesday, U.S. District Court Judge Mark Wolf ruled that Michelle Kosilek, an inmate in the Massachusetts Department of Correction system, is entitled to receive sex reassignment surgery. This decision follows a 10-year litigation process that Wolf described as “a prolonged violation of Kosilek’s Eighth Amendment right to adequate medical care.” Wolf is a 1985 Reagan appointee to the federal bench.
Despite the fact that the Supreme Court decided over three decades ago that inmates are Constitutionally entitled to care deemed necessary by prison medical officials, there still seems to be question about whether care provided to transgender prisoners is a “good use of taxpayer dollars” (in the words of Massachusetts Democratic Senate candidate Elizabeth Warren) or even whether it is an “outrageous abuse” of state funds (in the words of the sitting senator Warren is challenging, Republican Scott Brown).
But in fact, treating transgender people equally in providing medically necessary care is not only appropriate under the law, it is also the fiscally responsible thing to do.
Setting aside the generalized cost implications of providing transition-related services to transgender people, Massachusetts could have saved money by providing appropriate care in the first place. The State has spent over ten years in court arguing over whether the Department was required to cover transition-related care for Michelle Kosilek. In 2008 — four years ago — the Associated Press found that the Department had spent more than $52,000 on medical experts alone. That expenditure of taxpayer funds is itself double the estimated cost of surgery that Corrections physicians found was the only adequate treatment for Kosilek’s condition. Add in the litigation costs aside from medical experts, and another four years since the AP review, and the outcome is clear: Massachusetts officials chose to spend more money disputing the judgment of their own medical professionals than it would have by simply providing the care deemed appropriate by multiple expert medical organizations.
Furthermore, when transition-related care is provided to transgender people, data still suggests that nondiscrimination is fiscally sound policy. Like some commenting on the Kosilek decision, members of the City of San Francisco’s Health Service System Board expressed concern in the late 1990s that providing insurance coverage for transition-related care would encourage “abuse” of the system — transgender people may flock to City employment or marry city employees so that they could access inclusive benefits. However, in 2006, the City reported that none of this came to pass, and the actual costs associated with coverage were significantly less than projected – less than 1% of the initial estimates.
Permitting transgender people to access care related to transition also improves their health — meaning that fair treatment could actually cut costs. The California Department of Insurance, conducting an impact assessment of regulations implementing the state’s transgender nondiscrimination protections in insurance, found a drop in depression and anxiety among patients who had coverage for gender transition services. This improvement in mental health was so significant that the Department concluded that the “reduction in utilization of mental health services could be a source of cost savings.”
Cutting mental health care costs, improving inmate health, preventing excessive litigation expenses, and complying with the Eighth Amendment — all of these results point to the conclusion that providing medically necessary transition-related care to transgender inmates is the fiscally responsible thing for all states to do. The true “outrage” in this case is not that Massachusetts must treat Michelle Kosilek — it’s that our elected officials (and those who seek public office) still let bias and stigma, and not medical science or even arithmetic, guide their positions on issues of critical importance to transgender people.