No one, including DHS, knows how many transgender people receive Medicaid in Pennsylvania. But roughly 4,800 of the state's 1.6 million Medicaid recipients could benefit from dropping the exclusions, assuming about .3 percent of the general population is transgender, a widely cited rate that demographers acknowledge is an educated guess.
Seven other states and the District of Columbia have already taken steps to affirmatively provide such care, something Michael Silverman calls a trend.
Silverman, executive director of the New York based Transgender Legal Defense and Education Fund, argues Medicaid reform is especially important for the transgender population.
"Transgender people are far more likely to be unemployed or underemployed than the population at large," Silverman says. "As a result of that they tend to be poorer and more likely to receive health care through Medicaid programs across the country.
"Despite that, Medicaid programs ... routinely exclude transition-related health care [and] all that does is target transgender people for poor health outcomes that lead to unnecessary suffering and continued marginalization."
But getting the Medicaid restrictions lifted in Pennsylvania is politically tricky; advocates are nervous that conservative legislators will try to derail the process.
"I worry that if socially conservative legislators get wind of the possibility to make these changes without a big public fight," Ninehouser says, "they could use it as an opportunity to politicize and demonize transgender people and derail any attempt at ending discrimination in benefits."
One eventual way around a political fight could be to rely on an interpretation of the Affordable Care Act, which "prohibits discrimination [on] the basis of sex, and in the regulations, with respect to gender identity," according to Kellan Baker, a senior fellow at the Center for American Progress.
While Baker notes that it is not yet settled whether the ACA's non-discrimination provisions will require public and private plans to affirmatively cover transitional care, he points to the federal government's decision last year to cover transgender-related care under Medicare as a sign of where coverage is headed.
"The federal government has not taken any steps ... to require state Medicaid programs to require coverage for transgender people," Baker says. "But I think the indications of where we're going as a country, both in private and public coverage, is that these exclusions are, by nature, discriminatory."
But even if the writing is on the wall, there are plenty of trans Pennsylvanians who are caught in a system of inconsistent care where the prospect of a full transition remains out of reach.
Jordan Gwendolyn Davis was one of them. A trans woman, activist and Medicaid recipient, she recently moved to San Francisco from Philadelphia to take advantage of California's Medicaid program, which covers transition-related care — and will allow Davis to finally get surgery.
"People are really suffering right now," Davis says, noting that it was "tricky" to get even her hormones covered in Pennsylvania.
She says getting the regulations changed will in part depend on trans people mobilizing to advocate and tell their stories. "A lot of people don't have hope or think we're chasing rainbows. There needs to be unity. This is not impossible, merely an uphill battle," Davis says.
But she doesn't regret leaving Pennsylvania. Being in California "feels a lot better ... I can actually see a way out. I can actually be who I am and have the full surgery and move on," she says.