Chest masculinization surgery, often called gender-affirming top surgery, is considered medically necessary for many transgender and nonbinary people experiencing chest dysphoria, the distress arising from a mismatch between chest anatomy and gender identity. The operation encompasses a range of techniques tailored to individual anatomy and goals, with double-incision mastectomy with free nipple grafting the most common approach. The evidence base supporting the procedure has grown considerably. Prospective studies using validated instruments have documented significant reductions in depression and anxiety alongside improvements in body image and psychosocial functioning six months after surgery. Long-term follow-up of 139 patients two or more years postoperative reported median satisfaction scores of 5 out of 5 and decisional regret scores of 0 out of 100, with no participants seeking reversal.

Population-level data reinforce these individual outcomes. An analysis of national insurance claims found significantly lower rates of antidepressant use, suicidal ideation and attempts, and substance misuse among people with gender incongruence who had undergone gender-affirming surgery. A secondary analysis of the 2015 U.S. Transgender Survey, which included 27,715 respondents, found that those who had surgery at least two years earlier had significantly lower odds of past-month psychological distress, past-year suicidal ideation, and past-year tobacco use compared with those who desired but had not yet received surgery. Critically, the analysis controlled for prior transition-related care such as counseling and hormone therapy, isolating the surgical contribution. In the 2022 U.S. Transgender Survey of 22,285 respondents, 97 percent of those who had received surgery reported greater life satisfaction afterward.

The policy backdrop to the Cincinnati study is essential to interpreting its results. Medicare reversed its exclusion of gender-affirming surgery in 2014, and in 2016 the U.S. Department of Health and Human Services implemented Section 1557 of the Affordable Care Act, expanding the definition of sex discrimination to include gender identity and thereby prohibiting insurance discrimination against gender-affirming care. Federal regulations now prohibit categorical exclusions of such care in health plans receiving federal funding, and as of 2024, twenty-four states and the District of Columbia have enacted laws or regulations barring blanket exclusions in private insurance. The volume of surgery reflects this shift: one analysis documented a 152-fold increase in gender-affirming surgeries between 2010 and 2018, with the steepest growth, 257 percent, occurring in the Midwest during the implementation period of Section 1557.

Against that backdrop, the Cincinnati team assembled its cohort using the ICD-10 diagnosis code for gender incongruence and extracted demographic, clinical, and insurance data from the electronic medical record. The 128 patients had a mean age of 26.9 years, and 79 percent identified as transgender men while 21 percent identified as nonbinary. Public insurance was the norm, covering 64 percent of patients, including 57 percent on Medicaid. The vast majority of consultations, 90 percent, occurred in 2019 or later, underscoring how rapidly demand grew in the second half of the study window. All procedures were performed by the same group of surgeons throughout, which the authors note strengthens the internal consistency of the wait-time analysis.

The insurance findings are nuanced. Overall, 27 patients, or 21 percent, received at least one denial of prior authorization, and two-thirds of those denials came from public insurers. Yet the likelihood of denial did not differ significantly between public and private coverage, at 21 percent versus 20 percent. Seventeen of the 27 denied patients were ultimately approved after resubmission, while eight did not proceed and were lost to follow-up. Nonbinary patients were significantly less likely than transgender men to experience a denial, 7 percent versus 24 percent, a difference the authors attribute in part to the fact that all nonbinary patients were engaged in psychiatric care, which may have strengthened the medical necessity documentation supporting their authorization requests.

Wait times emerged as the study’s most policy-sensitive metric. The mean interval from initial consultation to surgery was 249 days, or roughly 8.2 months, with a median of 208 days. Publicly insured patients waited an average of 259 days compared with 218 days for the privately insured, a 41-day difference that was not statistically significant. Consultation year, by contrast, was strongly associated with wait time, with the shortest waits, 186 days, recorded in 2022. Neither insurance type assessed year by year nor the duration of gender-affirming hormone therapy independently predicted how long patients waited. That last result carries practical weight: hormone therapy duration requirements embedded in insurer policies appear to do little to expedite care, suggesting that timely progression depends more on coordinated documentation from primary care and mental health clinicians and on surgeons willing to engage in the appeals process.

Surgical outcomes added a further layer of complexity. Among the 89 patients, or 70 percent of the cohort, who underwent surgery, mean tissue resected was 875.2 grams and postoperative complications occurred in 11 percent, including infections requiring antibiotics, hematomas or seromas requiring drainage, delayed wound healing, and nipple necrosis. No patient required a return to the operating room. Nonbinary patients had significantly greater mean tissue resected than transgender men, 1410.6 grams versus 742.9 grams, and more frequently opted for a no-nipple result. They also experienced a significantly higher rate of postoperative infection, 16 percent versus 1 percent, though rates of seroma, delayed healing, and revision surgery did not differ by gender identity. The authors suggest the larger resection volumes may have contributed to the infection difference and note that similar revision rates between groups imply comparable achievement of desired aesthetic outcomes.

The study’s limitations are acknowledged candidly. Spanning nearly a decade of overlapping legal and policy changes, the retrospective design cannot isolate the effect of any single reform, and the analysis was not powered for granular year-by-year comparisons. Records may have omitted contextual details, and institutional factors are difficult to disentangle from broader trends. The single-center setting in a region without state-level nondiscrimination protections limits generalizability, particularly given that an estimated 44 percent of the LGBTQ population lives in states lacking such safeguards. Nationally, disparities persist: 28 percent of 2022 U.S. Transgender Survey respondents reported avoiding medical care due to cost, and 35 percent of those assigned female at birth who sought chest surgery reported a denial in the past year, with Medicaid recipients disproportionately affected.

Even so, the core message stands out with unusual clarity for health services research. Access to chest masculinization surgery at this Midwestern center improved primarily along a temporal gradient that tracks federal policy change, not along the insurance fault line that so often divides American health care. The authors conclude that federal policy shifts were associated with meaningful improvements in access across insurance types, even in a region lacking state-level protections, while cautioning that access remains tightly linked to policy and increasingly vulnerable to reversal amid ongoing federal reconsideration of gender identity protections under Section 1557. As the legal landscape evolves, they argue, research in the regions most exposed to policy change will be critical to understanding how these dynamics shape access to medically necessary care for transgender and nonbinary adults.

Subject of Research: Trends in insurance coverage and surgical wait times for gender-affirming chest masculinization surgery among transgender and nonbinary adults in the United States

Article Title: A decade under review—trends in insurance coverage and wait times for chest masculinization surgery in the United States

Article References: A decade under review—trends in insurance coverage and wait times for chest masculinization surgery in the United States. (n.d.). https://doi.org/10.1186/s44452-026-00020-0

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00020-0

Keywords: chest masculinization surgery, gender-affirming care, insurance denials, prior authorization, Affordable Care Act, Section 1557, transgender health, nonbinary patients, wait times, health policy, Medicaid, plastic surgery

The stakes of this gap are considerable. Serious emotional disturbance, defined as a mental, behavioral, or emotional disorder diagnosed before age 18 that causes significant functional impairment in family, school, and community life, affects an estimated 7 to 12 percent of the total U.S. youth population. Left untreated, these conditions carry a cascade of risks: school dropout, involvement with the juvenile justice system, repeated hospitalizations, and long-term residential placement. Roughly one-third of children with serious emotional disturbance also live with a chronic physical illness, with asthma the most common comorbidity. For families, the toll extends to relationships, employment, income, and physical health, and children with mental health disorders account for a remarkable 55 percent of Medicaid spending among 3-to-17-year-olds.

The Behavioral Health Home model was created under Section 2703 of the Affordable Care Act in 2010 as a way to knit together fragmented care. Its intellectual roots reach back to the Patient Centered Medical Home, a concept the American Academy of Pediatrics developed in the 1960s, but the Medicaid version targets high-need, high-cost populations and focuses on integrating mental, physical, and social care. The model pursues the so-called triple aim—better population health, better care quality, and lower costs—by embedding primary care services into community behavioral health settings, where many people with mental illness receive most of their care. Core components include preventive services, care coordination, population health management, transitional care, patient and family support, and referrals to community and social supports.

Typically nurse-led and team-based, though not standardized, the model gives states wide flexibility in design. Caseworkers, mental health counselors, psychiatrists, and peer support providers often play central roles, physician consultation is required, and expanded hours and service locations aim to improve access. Because federal rules require states offering health homes for serious mental health conditions to serve both adults and children, youth are enrolled in substantial numbers: roughly 20 percent of enrollment in Missouri, 13 percent in Maryland, and, under a dedicated State Plan Amendment, 100 percent of a Rhode Island program for children and youth with special healthcare needs.

Yet the evidence base underpinning the model was built almost entirely on adults with serious mental illness. Randomized trials and evaluations in adult populations have linked behavioral health home participation to improved primary care access, better screening and monitoring of cardiometabolic conditions, healthcare savings, reduced inpatient utilization, and higher patient satisfaction. But other comprehensive reviews found no significant effects on diabetes control, weight management, or smoking cessation, and only modest reductions in cardiometabolic risk with wide variability across studies. Researchers attribute these mixed real-world results to variations in implementation and the highly context-specific nature of a multilevel, multisystem intervention. Documented barriers in adult implementations include increased administrative load, financial constraints, difficulties with patient recruitment and retention, staffing problems, health information technology challenges, and misalignment between the model’s values and those of the host community mental health center.

Crucially, the review’s authors argue that children are not simply small adults in this context. Children with serious emotional disturbance typically have shorter enrollment periods, since their conditions often resolve with proper care, whereas adult behavioral health homes are designed as lifetime homes. Prevention carries greater weight in pediatric care, and children generally have fewer comorbid conditions. Most importantly, care coordination differs fundamentally: adult coordinators work mainly with primary and specialty medical providers, while children require coordination across child welfare, juvenile justice, and special education systems, each governed by legal mandates such as expedited health evaluations for children entering foster care. And where adult care is person-centered, pediatric care must be patient and family centered, incorporating the social and economic needs of the whole household.

The review itself followed rigorous PRISMA guidelines, with a protocol registered in PROSPERO. The team searched PubMed, CINAHL, and PsycINFO for studies published from 2010 through mid-2026, supplemented by a targeted gray literature search of state Medicaid agency websites and reports from policy research organizations. After removing 1,529 duplicates, reviewers screened 3,171 titles and abstracts, excluding 3,144 as unrelated to the intervention, focused on adults, or non-empirical. Twenty-seven full-text articles underwent independent dual review, and all 27 were excluded—most because they studied related integrated care models rather than the Medicaid Behavioral Health Home itself. Fifteen gray literature documents, including state program reports and evaluations from organizations such as the Urban Institute, were also assessed and all excluded for reasons ranging from unrelated outcomes to insufficient methodological rigor. Data extraction and coding using the Consolidated Framework for Implementation Research, the planned analytical lens, proved impossible because there was nothing to extract.

A null result of this kind is not a dead end but a redirection. Drawing on adjacent literatures—adult behavioral health homes, pediatric integrated care, and evidence-based parenting programs—the authors identify three likely battlegrounds for youth implementation. The first is family engagement. Unlike adult models, pediatric care depends on caregivers as the prime movers of treatment: they set routines around diet, sleep, and activity, model healthy behavior, and maintain continuity of care. Unmet caregiver psychosocial needs, stigma, distrust of health systems, fear of child welfare involvement, chaotic routines, and frequent residential moves all demonstrably reduce engagement in related programs. The authors suggest embedding family support providers with lived experience into care teams, giving program managers flexible assistance funds for urgent needs like transportation or utility bills, and pursuing broader policies on caregiver Medicaid coverage, housing, and childcare.

The second battleground is cross-system coordination. Adult implementation studies document fragmented organizational relationships, difficulty engaging primary care providers, inconsistent communication, and weak external partnerships—and colocation of services or data exchange alone proved insufficient to ensure coordination. For children, where coordination must extend into schools and courts, these challenges are likely amplified. Emerging evidence points to facilitators such as alternative payment models like Vermont’s hub-and-spoke structure and collaborative agreements emphasizing shared purpose, as seen in Ohio. The third battleground is measurement. The mandatory Health Home Core Set of quality measures skews toward adult-relevant indicators: Missouri’s 2024 pediatric measures included asthma medication adherence, diabetes control, and tobacco use, which capture only a sliver of enrolled youth. The authors point to promising alternatives, including North Carolina’s Integrated Care for Kids program, school attendance data sharing led by Children’s National Hospital, and cross-sector outcomes such as recidivism used by Multisystemic Therapy. Looking forward, they call for research grounded in implementation frameworks like the CFIR, hybrid effectiveness-implementation designs, and multi-axis conceptions of integration spanning vertical, horizontal, and longitudinal dimensions. Until such studies exist, the fate of a model serving some of the nation’s most vulnerable children rests on evidence borrowed from adults.

Subject of Research: Implementation barriers and facilitators of the Medicaid Behavioral Health Home model for children with serious emotional disturbance

Article Title: Opportunities to Strengthen Implementation of the Medicaid Behavioral Health Home Model for Children with Serious Emotional Disturbance: A Systematic Review

Article References: Winning Verry, T., Eisen, S., Farabi, S., Lengnick-Hall, R., & Dell, N. A. (2026). Opportunities to Strengthen Implementation of the Medicaid Behavioral Health Home Model for Children with Serious Emotional Disturbance: A Systematic Review. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01709-3

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01709-3

Keywords: Medicaid, Behavioral Health Home, serious emotional disturbance, children's mental health, integrated care, care coordination, implementation science, Affordable Care Act, family engagement, health services research, systematic review, population health