SANTA CRUZ, Calif. — From an early age, Pasha Wrangell felt different. Societal expectations of boys, and many characteristics of masculinity, did not match how Wrangell felt inside.

Bullied and ostracized, Wrangell started repressing those feelings in middle school and kept them bottled up for a long time. That led to decades of sadness, isolation, and even a couple of suicide attempts. What gnawed at Wrangell was gender dysphoria, a condition widely acknowledged in the medical community, which causes severe distress to people whose gender identity does not match their sex assigned at birth.

“It’s a sense of wrongness, like someone attached an arm to my head badly, and it just punches me in the face every time,” said Wrangell, 38, who grew up and still lives in this idyllic central California beach community. Facial and body hair is particularly upsetting: “I see my face in the mirror, and anytime I have to deal with hair, it is uncomfortable. I hate seeing it.”

Wrangell is nonbinary, meaning neither a man nor a woman, and uses the pronouns they and them. For over three years, they have been undergoing gender transition treatments to take on more feminine physical traits. These treatments have included genital transformation, known as bottom surgery; hormone replacement therapy using estradiol; and electrolysis hair removal for their face, neck, and chest.

All of it is paid for by Medi-Cal, California’s version of the federal Medicaid insurance program for people with low incomes. California law requires Medi-Cal and all other state-regulated health plans to cover gender-affirming care that is deemed medically necessary. But therein lies the rub.

Wrangell, an enrollee of the Central California Alliance for Health, the only Medi-Cal health plan in Santa Cruz, said it has been laborious to get the care they need. They contend with seemingly endless paperwork and phone calls to prove what they’ve already established — that their need for treatments is real and ongoing.

“There is a joke among the trans community, where they are always asking for letters, along the lines of, ‘Oh, did they think I stopped being trans or did the hair magically go away?’” Wrangell said.

And it requires a lot of work to find and vet the scant number of gender-affirming care providers who take Medi-Cal patients, Wrangell said.

Over 1.6 million people ages 13 and older in the U.S. are transgender, according to the UCLA School of Law’s Williams Institute, which conducts legal and policy research on gender identity and sexual orientation. Data from the institute shows an estimated 276,000 transgender people in the U.S. are enrolled in Medicaid, including 164,000 in states where transgender care is covered. Of those, 36,000 are in California, one of 25 states, plus Washington, D.C., whose Medicaid policies cover gender-affirming care.

“I think there’s a lot of pressure in society to fit into a very narrow set of narratives, and I don’t think honestly that works for most people,” Wrangell said. “For some people, it’s so ill-fitting, it’s disastrous.”

A national survey of transgender people shows they disproportionately experience physical abuse, economic hardship, and mental health problems. And research finds gender-affirming care can significantly enhance their quality of life.

But as Wrangell has learned, coverage and care are not the same thing. Hair removal, their top priority, has been hard to get. After 2½ years of electrolysis treatment, they’ve had roughly only about half the total number of hours their electrologist said they needed.

Permanently removing the facial hair of a transgender person assigned male at birth can require 400 or more hours of electrolysis spread over several years. For those paying out of their own pockets, the cost would easily reach tens of thousands of dollars. That doesn’t include the cost of facial, bottom, and body-shaping surgeries.

Wrangell said their health plan has limited the number of sessions it authorizes at a time, requiring constant reauthorization.

Dennis Hsieh, deputy chief medical officer of the Central California Alliance for Health, said the health plan recently updated its policy to allow 50% more electrolysis in a three-month period and eliminate a rule requiring patients to submit photos of relevant body parts.

Hsieh acknowledged a shortage of providers and said the alliance contracts with clinicians across several counties to provide more options.

To a large extent, the challenges transgender people encounter seeking care are the same ones many people face in the “terror dome of U.S. health care,” said Kellan Baker, the executive director of the Washington, D.C.-based Whitman-Walker Institute, which conducts research and education on topics of concern to gay, bisexual, and transgender people. “There are a lot of people in a lot of circumstances who cannot get medically necessary care for their conditions, whether that’s gender dysphoria or cancer or diabetes.”

Legal aid lawyers and transgender activists say another big reason for denials or delays in gender-affirming care, especially hair removal, is that many people in the medical world still think of it as cosmetic.

Medi-Cal, like most commercial insurance plans, does not cover cosmetic treatments. “But if it’s affecting your mental health, and it’s affecting your life opportunities, and it’s affecting your ability to get a job, and it’s affecting your ability to get housing, is that cosmetic?” asked Elana Redfield, the federal policy director at the Williams Institute.

Despite their travails in obtaining care, Wrangell said, the treatment is improving their life. The estradiol, they said, makes them feel “way more relaxed, much less on edge all the time.” And Wrangell feels good about an uncommon bottom surgery they got last October, but they are facing more paperwork for a needed follow-up operation.

They are frustrated about all the red tape they’ve encountered, precisely because the treatments are helping. “This is working,” Wrangell said. “Please finish it.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.