When Addie realized she was trans in her late teens, she knew tackling the costs of transitioning would be an uphill battle. Having run away from her small-town home in Alberta, to work fulltime as a drag performer in Calgary, she had no employer insurance and no family fund to lean on. 

For instance, it cost her more than $200 a month to get on a blocker and on HRT in 2021, all paid out of pocket. At the time, that was as much as she made for an entire night of performing. 

“At that point, I thought I’d do whatever it takes,” says Addie, who asked to be referred to by her first name only to respect her privacy. “I didn’t give a fuck how much it was, I was doing it.”

In the years following, Addie moved to Vancouver and got facial feminization surgery. Altogether, the now 23-year-old estimates she’s spent nearly $40,000 on her medical transition–paid for with the help of a GoFundMe, performance nights that doubled as fundraisers and lots of credit card debt. “The debt incurred was definitely worth it for me–I’m so much happier in general.”
 

But now, she’s relieved that debt won’t grow as her monthly HRT costs have shrunk to zero thanks to a new program that extends coverage for some prescriptions. In March, B.C. joined the likes of Manitoba, Prince Edward Island and Yukon in partnering with the federal government on the national pharmacare program. 

It’s a big step forward for the federal government’s national pharmacare plan—as B.C.’s addition more than triples the number of Canadians covered under it. 

It’s also fairly targeted in scope, with the plan focused on paying only for treatments and devices in the realms of birth control, diabetes and menopause.
 

While gender-affirming care is not on that list, nor an explicitly stated benefit of the pharmacare program, Script has confirmed with B.C.’s Ministry of Health that the coverage is age- and gender-agnostic. That means anyone—including transfeminine people of any age, can access the HRT medications listed on the plan. This encompasses estrogen, estradiol, progesterone and medroxyprogesterone—all free of charge. No co-pay, no dispensing fee.
 

“It’s very appreciated. It makes me feel like a valued part of society, that I’m respected and seen by the healthcare system,” says Addie.
 

Addie is not the only queer or trans person concerned about their long-term health costs. According to Pink Triangle Press’s Pink Paper exploring health disparities in Canada, nearly half (42 percent) of LGBTQ2S+ responders say affording their healthcare or medications is a major concern. (Pink Triangle Press is Script’s parent company.) So this new coverage is a good thing for trans women in B.C., though not everyone might realize that. 
 

“The press releases are geared toward cis people, so it’s easy to look at that and be like, ‘Okay, this is not for me,’” says Clio Lake, director at the B.C.-based Society for Advocacy for Gender-Affirming Healthcare (SAGAH). “It takes a little bit of sort of knowledge of how the healthcare system works to read through the fine print.”

SAGAH had been campaigning for B.C. to join the national plan and celebrated when they did so, but Lake acknowledges that not everything they’d asked for materialized.
 

“We advocated hard for coverage of injectables, and we unfortunately didn’t achieve that,” they say. Under this plan, the aforementioned hormones are only covered in oral and topical forms.

Lake outlines the problems with oral HRTs, starting with the fact that it’s a less direct delivery—passing through the metabolic system first. As well, because oral HRT has a shorter duration in the body, some people take multiple doses at once. Finally, since menopausal treatment is the overarching goal of the covered HRT, anti-androgens, such as spironolactone—which some transfeminine people take—are not included. 

Nor is testosterone, which shuts transmasculine patients out. But transmascs in B.C. should still take a look at the province’s new coverage, says Lake. Vaginal estrogen, for instance, is covered by the plan and could be used by trans people on testosterone to deal with the sexual side effects associated with being on the medication. Likewise, trans or non-binary people may choose to use the covered birth control methods to stop their periods, if having a period causes them dysphoria.
 

As for why the plan wouldn’t take a step further to include other delivery methods for HRT, or why only four of Canada’s 13 provinces and territories have signed on, the answer could be simple: “It’s politics and, basically, money,” says Elizabeth Kwan, a senior researcher and the healthcare policy lead at the Canadian Labour Congress (CLC).
 

As a national body, the CLC has been pushing for a more fulsome and comprehensive pharmacare plan for all Canadians—especially considering Canada is the only G7 country with universal healthcare, but without a universal drug plan.

This seems unlikely to change soon: under Prime Minister Mark Carney, the Liberal government has reportedly stopped negotiations with other provinces and territories to expand the pharmacare program. According to Newfoundland’s health minister Lela Evans, the federal government has decided to run the program as a pilot project, including only those regions that have already signed on. “The door was closed on our province,” Evans told reporters at a press conference last week. 
 

The federal health minister’s office told the CBC in a statement that Canada is still investing in healthcare access across all provinces and territories, but did not confirm whether or not the pharmacare plan would expand further. 
 

And even among those regions with plans in place, what is covered within each varies depending on what the individual provincial or territorial government negotiated. For instance, patches and inserts (a capsule that goes under the skin and releases hormones over time) are covered in Manitoba’s “national” plan, but not B.C.’s. “It’s a patchwork system on top of an existing patchwork system,” says Kwan.
 

This is because, she explains, insurance companies already take on the more than $40 billion in annual prescription costs—and no government is eager to foot that bill. That’s why we get small, cautious and, most importantly, cost-manageable expansions to pharmacare, like the one happening in B.C. But there are risks to letting insurance companies continue running the pharma show. 

“Insurance companies are not there for the public good—they’re there for their own profits,” says Kwan. “The federal [health] minister needs to go out and aggressively, intentionally and actively continue to negotiate these agreements with the remaining provinces.”

Under a patchwork system, trans people are left to find—and potentially relocate to—the places most accommodating to their needs, a process often referred to as “medical migration.”
 

“I’ve seen that in the research I’ve done—people are generally moving to places where they are feeling less targeted and if there’s more access to medications,” says Mikayla Hunter, a fellow at SPECTRUM—a progressive collective of researchers and academics based in Manitoba, with Hunter’s research focusing on LGBTQ2s+ health and social inequity. “Those two things are closely related, because fear and attacks can come from within the healthcare setting and are in themselves types of hate that people want to escape.”
 

The Maritime provinces and Yukon, for instance, have developed a reputation for having particularly accommodating healthcare systems—even paying for tracheal shaves, procedures that reduce the size of one’s Adam’s apple. But it’s not just about chasing good coverage, says Hunter. People also heavily weigh the access they could lose. “In places like Alberta, for example, access to gender-affirming care is becoming increasingly uncertain. I think that’s part of why we’re seeing people moving provinces.”
 

A truly national pharmacare plan—one enshrined for every Canadian—would help guard against attempts to limit care for the trans community by transphobic movements. It’s why exercising your voice wherever possible—in letter-writing to politicians, in asking about trans care during elections—is so important. 

“Put your own safety first because it can be scary out there, but a lot of what we can do as citizens, as people who have voting power, is vote accordingly,” says Hunter. “Every vote counts.” 

This story was produced in collaboration with Xtra.