The prohibition abruptly expanded to include adults hours before the House passed the bill, escalating the crackdown on transgender care once focused on children.
By Fenit Nirappil and Casey Parks
Transgender people of all ages would no longer receive gender transition care through Medicaid under a late addition to the massive tax and immigration legislation the House passed this week.
The measure marks an escalation from Republicans in Washington, whose efforts to crackdown on transgender care have mainly focused on treatments for children and adolescents.
Earlier versions of a House bill to finance an extension of President Donald Trump’s 2017 tax breaks, in part through deep social services spending cuts, included language to bar Medicaid and the Children’s Health Insurance Program from covering transition care for minors. Such care includes puberty blockers, hormone treatments and body-altering procedures.
But the prohibition expanded to include adults through a “manager’s amendment,” which reflects deals Republican leaders made to appease their party’s holdouts, introduced hours before the legislation’s early Thursday passage.
“This is the next attack in their assault on the health care of transgender people, and they won’t stop here,” said Tyler Hack, executive director of the Christopher Street Project, a transgender rights advocacy group. “It is life or death for trans Americans in this moment, and it’s reprehensible.”
Rep. Dan Crenshaw (R-Texas), who had been pushing for a prohibition on federal funds for insurance coverage of transition care for minors, welcomed the provision making it into the final bill and including all age groups.
“Gender transition procedures are the lobotomy of our generation,” Crenshaw said in a statement. “So-called ‘gender affirming care’ isn’t healthcare — it’s fringe science with no proven benefit and massive risks.”
Nearly every major medical association has endorsed transition care as “medically necessary,” but Republicans have moved to outlaw it in recent years. Most Republican-led states have enacted restrictions for youth access, and new waves of legislation in state houses target care for adults. Ten states have banned both adults and young people from using Medicaid to pay for gender-transition care, while another three have banned only minors from using it, according to the Movement Advancement Project, an LGBTQ+ issues think tank.
Judges have blocked some of those from taking effect, and the U.S. Court of Appeals for the Fourth Circuit last year called bans in West Virginia and North Carolina “obviously discriminatory,” but the states appealed and other bans remain in effect.
The GOP-controlled Senate is expected to make major revisions to the sprawling bill, which Republicans hope will advance the Trump administration’s agenda, including curtailing immigration and boosting defense spending. While LGBTQ+ advocates don’t expect Republican senators to push back on the transgender care provisions, they are hoping they could be scrapped on procedural grounds or the overall legislation won’t pass because of GOP infighting.
The nonpartisan Congressional Budget Office estimated a national limit on youth transition care would result in $800 million in savings over a decade. Similar estimates were not available for adults.
An estimated 12 percent of transgender adults, or 180,000, use Medicaid, according to a recent report by the Williams Institute at the UCLA School of Law, an LGBTQ+ research center. It’s unclear how many of them receive gender transition services.
Jay, who spoke on the condition his last name not be published because he is not out to co-workers and to protect his medical privacy, has used Medicaid to pay for testosterone and other transition care for the last decade. The 25-year-old trans man works at a gas station in Washington state, a job that barely covers his expenses. His testosterone prescription costs $136.49 for two weeks — a sum he said he can’t cover himself if the ban takes effect.
Though Jay lives in one of the country’s most liberal states, he said he has been fearful he’d lose coverage since Trump signed a slew of executive orders targeting trans people earlier this year. Jay has been trying to find a way to pursue a more lucrative career, and this month, he decided to have a hysterectomy while his insurance still covers the procedure.
Jay said he worries how he’ll make it through if the ban forces him to go without his medication. Health experts warn that patients who are on long-term hormone treatments can experience serious medical consequences if they stop taking them. Trans men who stop taking testosterone could experience side effects similar to menopause, doctors say.
“The times that I have had low testosterone, I can physically feel it,” Jay said. “It’s like an out-of-body experience for me. I’m not quite there, and my body feels like it’s missing something.
The tax legislation also alters the 2010 Affordable Care Act, which previously did not exclude or require coverage of transition care, to prohibit states from deeming “gender transition procedures,” including puberty blockers, hormone treatment, and surgery, as an “essential health benefit” on or after Jan. 1, 2027.
That would make it more expensive to receive transition care through insurance plans purchased through ACA exchanges, according to Lindsey Dawson, associate director of HIV Policy and director of LGBTQ Health Policy at KFF, a health policy organization. If transition care is not considered an essential health benefit, patients would lose protections to minimize out-of-pocket payments.
Earlier this month, an Associated Press-NORC Center for Public Affairs Research poll found that most Americans oppose the use of public funds for transition care. In a survey of 1,175 adults, the groups found that 66 percent either strongly or somewhat oppose using Medicaid dollars to help minors transition, and 53 percent oppose using public tax dollars on adult transition care.
Mehmet Oz, director of the Centers for Medicare & Medicaid Services, in April sent a letter to state Medicaid directors discouraging them from covering gender transition care for children and adolescents, but it was not legally binding. The letter did not address care for adults.
Some LGBTQ+ advocates and researchers say the targeting of adult access to care comes as no surprise. The Department of Veterans Affairs moved to phase out gender transition care for veterans to comply with a Trump executive order asserting sex is not changeable. A report commissioned by the Department of Health and Human Services to criticize the use of gender transition care for children and teens also dismissed the concept of a person having a gender that differs from their sex at birth.
“The way that the administration has approached gender affirming care has been to categorically discredit it,” said Elana Redfield, federal policy director at the Williams Institute.
Even if Medicaid no longer covers his transition care, Jay said the government can’t take away his identity.
“I’ll still be a trans person with or without my hormones,” Jay said. “These bans won’t stop me or others from being trans.”
Emily Guskin contributed to this report.
