Part of the answer lies with the Affordable Care Act of 2010, which indirectly forced health insurance companies to cover hormones and surgeries by barring health insurance companies from discriminating based on sexual orientation and gender identity. This meant that if insurance companies provided hormones (like birth control) to the non-transgendered, it had to also provide the expensive cross-sex version to the transgender-identified. If health insurance companies were going to cover breast reductions for anyone, they had also to cover double mastectomies for the gender dysphoric;
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