Michelle Storm has spent her life closing her eyes when she takes a shower.
She knew in grade school that she is female, not the boy her parents thought they were raising. As an adult, after a stint in the Army, she legally changed her name and started referring to herself as "she." And then she started taking estrogen.
That was nearly two decades ago. The 42-year-old still feels queasy when she removes her clothes. What she wants most is a surgery she says will finally finish correcting her gender.
"I hate the anatomy I currently have," she said, "with an utter passion."
Last year, for the first time, the Oregon Health Plan decided to cover medical services for low-income transgender people. Since then, doctors, insurance representatives and even a U.S. senator have tried to help Storm, an Army veteran who cannot afford the $30,000 surgery, to get what she needs.
More than a year later, she is still waiting.
The state opened the door to these broad new public health benefits for transgender men and women with the best of intentions. But regulators were caught off guard and ill prepared to help people such as Storm, interviews with 75 patients, physicians, activists and Medicaid employees show. Even today, gaps remain and necessary systems are lacking.
As a result, patients haven't found doctors to provide even basic hormone treatments, let alone gender reassignment surgery. Transgender Oregonians said they have encountered discrimination because medical staff have not been trained in transgender issues. They say they have been denied treatment by doctors who feared providing services in areas where they had no experience.
Health care leaders cited a variety of reasons for the rash of problems. They said Oregon does not have enough doctors and therapists willing or able to treat transgender patients. They say providers have submitted incorrect billing codes, slowing the approval process. And many patients haven't yet fulfilled the prerequisites for surgery, which include taking a year of hormones and finding two therapists to endorse their gender transition.
But it's clear the state has been overwhelmed since it announced new health benefits that include hormone therapy and sex reassignment surgery for people living in poverty.
State regulators estimated 175 patients would use the benefit in 2015. They projected it would cost taxpayers less than $150,000 annually. But more than 700 people used it last year for therapy, hormones and chest surgery. The budget is now three times what state leaders anticipated.