Medical expenses

Bills restricting gender-affirming care advances

The N.C. House passed Wednesday a controversial Republican-sponsored Senate bill that prohibits the use of public health-care facilities and state funds for gender transition procedures on those under age 18.

Senate Bill 631 cleared the House by a 66-47 vote along party lines.

The bill goes back to the Senate, which can approve or reject House changes to SB631. It would take effect on Oct. 1 if it becomes law.

Meanwhile, a Senate committee advanced a House bill that would restrict how most surgical gender transition procedures are performed for children, but only after establishing several exemptions requiring informed parental consent.

Republican-sponsored House Bill 808 cleared the Senate Health Care Committee, also along party lines, following more than 40 minutes of often emotional discussion among committee members and public speakers.

The Senate Judiciary committee is scheduled to address HB808 at 10 a.m. Thursday.

The two bills have been put on a fast track as the legislature has entered what is expected to be its final weeks of the regular session.

House Republicans required less than 30 hours to pass SB631, which was subject to the gut-and-replace legislation strategy on the Senate version of the transgender sports bill.

SB631 would prohibit public health care facilities, including public hospitals and University of North Carolina affiliates, from performing any surgical gender transition procedure on a minor, or providing them with puberty-blocking drugs or cross-sex hormones.

Rep. Timothy Reeder, R-Pitt, and an emergency physician, applied during the House floor debate the Republican refrain that SB631 is “a common-sense bill that seeks to prevent these unproven treatments on children.”

“The bill is not an attempt to limit treatment for children who are suffering from gender dysphoria or those struggling to form their identity.”

“Rather, this seeks to limit children from potentially life-altering treatments before they are truly able to understand and consent to these interventions.”

Rep. Julie Van Haefen, D-Wake, said during the floor debate on SB631 that the bill “essentially removes the ability of parents to make those (health care) decisions for their own children, to choose where they want to seek care, or the ability to even be able to pay for that care.”

“It limits your rights as a parent to direct your child’s medical care.”

House Bill 808

HB808 is focused primarily on “establishing governing standards for the provision of surgical gender transition procedures” to those under age 18.

The bill still has to go through Senate Judiciary, and Rules and Operations committees before a potential floor vote.

HB808 was approved by a 74-44 vote on May 3 with Democratic Reps. Garland Pierce of Hoke County and Michael Wray of Halifax County in support.

The bill also would take effect on Oct. 1 if it becomes law.

A legislative analysis of an amendment to HB808 submitted Wednesday by Sen. Joyce Krawiec, R-Forsyth, said medical professionals would be prohibited from: performing surgical gender transition procedures on minors; and prescribing, providing or dispensing puberty-blocking drugs or cross-sex hormones to minors with some exceptions.

Medical professionals determined to be in violation of HB808 would have their licenses revoked.

Minors who underwent a surgical gender transition procedure, or who were prescribed or provided with puberty-blocking drugs or cross-sex hormones, could sue the medical provider who performed the procedure or prescribed and/or provided the drugs.

State funds could not be used for surgical gender transition procedures on minors and prescribing, providing or dispensing puberty-blocking drugs or cross-sex hormones to minors.

Parental rights debate

Krawiec, who was shepherding HB808 during the committee meeting, was asked by Sen. Mujtaba Mohammed, D-Mecklenburg, to explain supporting legislation restricting parental rights toward gender-affirming care while also supporting expanding parental rights in Republican-sponsored Senate Bill 49 that she co-sponsors.

SB49’s focus is to enhance parents’ rights “to direct the upbringing, education, health care and mental health of their minor children.” The bill cleared the Senate K-12 Education committee Wednesday.

A similar comparison of SB49 and SB631 was made by several House Democrats during the committee and floor discussions.

Van Haefen said she was puzzled by how Republican bill sponsors could support enhancing parental rights on health-care issues in SB49, but move to take them away in SB631.

Examples are requiring parents to be informed if their child wants to alter their name or pronoun(s) as part of a gender identity issue, or prohibiting school districts from preventing school employees from notifying a parent about concerning changes in their child’s mental, emotional and physical health.

SB631 also prevents a health-care practitioner and facility from providing, soliciting or arranging medical treatment for a minor child without first obtaining written or document consent from a parent.

Krawiec said that in HB808, “parents still have the right to approve (gender affirming care), but there’s criteria that’s laid out for it.”

The amendment establishes a set of exemptions that includes allowing “any course of treatment that was initiated prior to Oct. 1 could be continued or completed provided that a medical professional deemed the continuation or completion to be medically necessary and the parents or guardians consented.”

The Associated Press reports that gender-affirming treatments for gender dysphoria are considered safe and medically necessary by the leading professional health associations, including the American Academy of Pediatrics, the American Medical Association and the Endocrine Society.

Krawiec cited studies that if children experiencing gender dysphoria are allowed to go through puberty, “80% and 67% of them have no further problems and they don’t proceed any further with it as long as they delayed the puberty blocking drugs.”

“Chances are they are going to much better off” having not started the transitioning process, Krawiec said.

Mohammed responded by saying that current law requires informed consent by parents and guardians — including consulting with appropriate health care provider — to proceed with gender-affirming care for their child.

“These are questions about individual liberties and freedoms, deeply personal issues,” Mohammed said.

“Why does the government need to get involved in this access to this particular type of health care?”

Krawiec answered by saying “the state does have a right to protect our citizens, and we want to make sure that they are going through every avenue to make sure we are doing the right thing for our minor children.”

“The state does have a vested interest.”

Arkansas law halted

SB631 cleared the House and HB808 was recommended by the Senate committee after a federal judge Tuesday struck down Arkansas’ 2021 ban on gender-affirming care for minors.

U.S. District Judge Jay Moody ruled the nation’s first ban on such care for children violates the U.S. Constitution. The law prohibited doctors from providing gender-affirming hormone treatment, puberty blockers or surgery to anyone under 18. It also prohibited doctors from referring patients elsewhere for such care.

N.C. Sen. Julie Mayfield, D-Buncombe, cited the ruling Wednesday because she said much of HB808’s language is very similar to the Arkansas restrictions.

“I think we know that if we pass this bill, we will be sued,” Mayfield said.

“There is no question about that. This is litigation that is going to proceed in every state that has passed” similar legislation.

According to AP, at least 20 states have enacted laws restricting or banning gender-affirming care for transgender minors.

“I would suggest to us that we have a better way to spend our money, and we let other states fight this fight,” Mayfield said.

“When those are settled, likely at the U.S. Supreme Court, then we can deal with it. Until then, I would encourage us to stay out of families’ lives, and let parents do what they need to do for their child.”

State Health Plan element

SB631 addresses a federal court ruling that requires the State Health Plan pay for medical treatments, including hormone therapy and surgeries, for transgender individuals.

State Treasurer Dale Folwell opposes the requirement, citing the SHP’s lawsuit “is about requiring taxpayers to fund sex transition procedures.”

The SHP has spent about $356,000 this year through April 30 on treatments for 270 individuals. It projects spending more than $1 million on treatment expenses in 2023, but that amount does not account for paid pharmaceutical claims.

According to the treasurer’s office, the overall projected membership expenditure is $2.79 billion for 2023.

Judge Loretta Biggs of the Middle District of N.C. ruled in June 2022 in favor of plaintiffs in the case of Kadel v. Folwell.

The lawsuit was filed by Lambda Legal and the Transgender Legal Defense & Education Fund in March 2019. Plaintiffs included several transgender people and their parents who sued because a temporary benefit to pay for surgical and hormonal treatments related to gender dysphoria had expired.

Biggs’ order required the state’s health plan to resume coverage.

Folwell appealed Biggs’ ruling to the U.S. Fourth Circuit appeals court in Richmond, Va., which heard oral arguments in January. A hearing before the full court is scheduled for September.

“The facts are on our side, and we hope the Fourth Circuit will apply the law and reverse Judge Biggs’ decision,” Folwell said.

If Folwell’s appeal is successful, the SHP funding requirement would be subject to SB631 restrictions.

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