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This question originally appeared on Quora. Answer by Jae Alexis Lee.

As surgery goes… SRS isn’t horribly expensive in either absolute terms or relative terms. I mean… compare it to what it costs to get a heart transplant, that’s close to $1M. (Transplant Living | Financing A Transplant | Costs.)

Don’t get me wrong, SRS can be seem expensive if you’re not used to looking at medical care costs, but when you put it in the context of other types of surgical medical care… it really isn’t that tremendously expensive.

The problem with SRS is that it is rarely covered by insurance. Because it is rarely covered, patients are left to bear the full cost of the procedure. While a patient needing laparoscopic hernia repair might need to cough up a $1,500 deductible and then a percentage until they hit their Out Of Pocket Maximum for the year, a trans patient having SRS is frequently on the hook for the entire cost.

Now, that’s changing, but the change has created a different problem. More and more insurers have been pressured into offering trans inclusive benefits. In some cases, this pressure comes from state non-discrimination laws, in others the pressure comes from employers and in some cases it comes from state insurance commissions. In 2016, the Obama administration gave direction that all insurance plans needed to be inclusive based on non-discrimination clauses in the Affordable Care Act, however, the State of Texas (joined by several other states) sued in the 5th circuit for an injunction blocking the Obama administration’s direction and that injunction was granted. This leaves us (in the US) in legal limbo on the issue.

But that different problem? With more insurers covering SRS, surgeons who perform SRS are buried with more patients than they can possibly treat. Finding surgeons with waiting lists between 2 and 3 years long isn’t uncommon. We have a shortage of trained surgeons globally and it is a mathematical impossibility for every trans patient who wants SRS to actually get surgery with the limited number of surgeons practicing. Demand exceeds supply by multiple orders of magnitude. In that environment, there’s little pressure to bring prices down, though there is a doctor in Thailand who does SRS without general anesthesia for around $2,000 USD… Personally, I don’t know how to feel about that one.

So, why so expensive? Because it’s a complex surgery with a limited number of trained specialists capable of performing it and a near endless supply of people who want the surgery. And it’s expensive because medical care (especially in the US) is frequently expensive and SRS frequently isn’t covered by insurance leaving the patient to bear the full burden of the already high health care costs we deal with.

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