Kina D’Angelo was 5 years old when she first remembers feeling like she was in the wrong body.

Now, at 27, after years of living in hiding, she has decided to change that.

But she and about 50 other transgender patients in Los Angeles County have been forced to wait for life-altering surgeries because there are not enough qualified surgeons who will accept their insurance.

Some patients, including D’Angelo, have been waiting close to a year for gender reassignment surgery, a procedure that will match their sexual characteristics to the gender they identify with.

“It sucks, I wish I could have transitioned a long time ago,” D’Angelo said. “I’ve been transitioning for about two years now, but this is just drawing the process out.”

The federal Affordable Care Act mandates that insurers cover transgender health care, including gender reassignment surgery, but many insurance plans that serve low-income people in Southern California have been slow to comply with the law, said Jim Mangia, CEO and president of St. John’s Well Child & Family Center, which operates the largest transgender health clinic in California.

“There are basically no surgeons in Southern California that will provide gender reassignment surgery for Medi-Cal or publically insured patients, which is a large proportion of the population,” he said.

Doctors are bound by anti-discrimination laws, but are not required to perform gender reassignment surgeries. Insurance companies, however, are supposed to ensure that patients have access to those procedures, which may mean paying for patients to travel to a surgeon or paying for an out-of-network procedure.

If insurers aren’t ensuring that access, “That’s violating the law, and whether it’s deliberate or inadvertent, it has the same effect on our patients, and it’s very serious,” Mangia said.

Dozens, if not hundreds, of transgender patients across California are being forced to wait indefinitely for gender reassignment surgery or pay their own way to the Bay Area to see one of the few qualified surgeons in the state who accept Medi-Cal.

Medi-Cal is California’s low-income health plan. A third of the state is enrolled in the plan — 13.5 million people.

State puts responsibility on health plans

The California Department of Health Care Services, which oversees Medi-Cal, said it does not have a list of surgeons who perform gender reassignment surgery in the state, and that it is the responsibility of the health plans it contracts with to ensure that patients have access to surgery.

“All Medi-Cal managed care health plans must cover transgender services which may include gender reassignment surgery that is not cosmetic in nature,” said spokesperson Katharine Weir. “There are limited specialists statewide that provide these types of services.”

If there isn’t a surgeon available in the health plan’s network, the insurer must allow the patient to receive the services out-of-network, she said.

Mangia, who oversees a network of clinics in L.A. County, said the state agency should do more to enforce the law and ensure that transgender patients have access to health care.

“We have a huge waiting list of patients, who are waiting for surgery, and there’s a barrier to realizing the law,” he said. “It’s a serious access violation, and it impacts the health and human rights of these patients.”

Many patients experience psychological distress when they are forced to wait for surgery, Mangia said. Those who are waiting are typically in the middle of transitioning, and unnecessarily prolonging that process can contribute to depression and anxiety.

At a meeting in June, the Medi-Cal Managed Care Advisory Group was scheduled to discuss the fact that there aren’t enough qualified surgeons in L.A. County to perform gender reassignment surgery. The Health Care Services department issued a response to that discussion in early September, noting that there is a “high-demand and limited number of surgeons who specialize in GRS.” The agency said that many health plans have developed or are in the process of developing programs to help transgender patients access services.

“DHCS is aware of the shortage of specialized surgeons that runs across all lines of business in addition to the Medi-Cal line and continues to partner with the MCPs (managed care plans) to ensure transgender services are being provided in a timely manner,” the agency said in the letter.

Mangia said one Medi-Cal health plan, the nonprofit L.A. Care, has been working to find surgeons in the area. Los Angeles-area patients who have other Medi-Cal health plans have reported difficulty getting those plans to cover transgender services, so St. John’s typically advises patients to switch to L.A. Care in order to recieve treatment more quickly, he said.

“All they want is to be allowed to live in the gender to which they feel they are,” he said. Mangia’s organization started a transgender health clinic two years ago in South Los Angeles, and now has about 1,200 transgender patients.

Patients forced to wait

There are a few gender-reassignment surgeons in the Bay Area who accept Medi-Cal, and some patients are opting to travel there to get the procedure, Mangia said.

But that is cost-prohibitive for many Medi-Cal patients who, in most cases, have incomes below the poverty line.

D’Angelo’s plan is to drive from her home in Long Beach to San Francisco to get the surgery. L.A. Care has told her it will pay for her lodging while she undergoes the surgery, but she is responsible for her transportation costs. L.A. Care did not immediately respond to questions for this story.

For someone with gender dysphoria, a condition where her body doesn’t match her identified gender, the procedure will be life-changing.

D’Angelo was born with male anatomy, but even as a young child, she felt more like herself when she could dress up in her mother’s clothes and makeup.

She was serving in the U.S. Marine Corps in 2009 when she first began to explore the idea of transitioning from a man to a woman. But when D’Angelo brought it up with her supervisors, she encountered transphobia and discrimination.

“They told me that I was unfit for duty and discharged me,” she said.

In June, Defense Secretary Ashton Carter lifted the ban on transgender persons serving openly in the U.S. military. However, the military still refuses to pay for gender reassignment surgery.

Now that D’Angelo is out of the military, she should legally have access to the surgery. She’s spent more than two years preparing for it, and has seen a behavioral therapist, psychologist and doctor to get their approval, steps that were required before she could meet with a surgeon.

In late August, she had a consultation phone interview with the surgeon, and she was hoping to finally be able to schedule the procedure. The appointment is unlikely to be soon, however.

“From what I’ve gathered and what the advocate told me, the earliest date is around December or January,” she said. “There’s a waitlist of about five months just to get a consultation.”