Gender-affirming care targeted in bill
Budget measure that passed House strips coverage for many seeking treatments
buried in President trump’s socalled big beautiful bill that passed the House early thursday are sweeping provisions that strip gender-affirming care from nearly all transgender Americans.
trump has made it a mission to sharply restrict access to gender transition treatments for minors, issuing an executive order to that effect his first week in office. but the new bill goes much further.
It prohibits medicaid or children’s Health Insurance Program funding for any gender-affirming care, including puberty blockers, hormone therapy, and surgeries, for Americans of all ages.
A second measure reaches further still; it would require the Affordable care Act to exclude these types of services from the definition of “essential health benefits,” which are the most basic health services that all health insurance plans in the ACA must cover, such as hospitalizations and prescription drugs.
the measure, if approved by congress, would go into effect in January 2027.
that doesn’t mean private insurance plans can’t cover gender-affirming care, but it makes it much less likely they will do so, said sean cahill, director of health policy research at the fenway Institute, which is part of fenway Health, the largest provider of transgender health care in new england.
‘To deny people medically necessary health care, it’s discriminatory, and it’s cruel.’ sean CAHILL, director of health policy research, the Fenway Institute
“To deny people medically necessary health care, it’s discriminatory, and it’s cruel,” Cahill said.
He said transgender people are more likely to be low-income than the general population and so probably rely more on medicaid. The proposed new measures threaten to exacerbate already existing health disparities in the transgender population and anti-transgender discrimination in health care, Cahill said.
The idea of prohibiting the use of medicaid funds for gender-affirming care has been percolating within the Republican Party and at the state level for some time.
Ten states, including florida, south Carolina, Tennessee, and Kentucky, already have state medicaid policies that explicitly exclude transgender-related health care for all ages, according to the movement advancement Project, a Colorado think tank.
but in about two dozen other states, including massachusetts, the state medicaid policy explicitly covers transgender-related health care.
“This care is evidence-based, medically necessary, and endorsed by every major medical society in the United states,” Cahill said. “Ultimately this will cost our health system more in disease care and cost our economy more due to lost productivity.”
fenway is planning to lobby massachusetts’ congressional delegation to push back against the measure as it proceeds to the senate.
Public opinion across the country seems to be aligned with Trump’s agenda on this issue.
a recent poll by the associated Press and the norc Center for Public affairs Research at the University of Chicago found that a majority of those surveyed opposed gender-affirming medical treatment covered by public health insurance, like medicaid, for adults or children.
masshealth, massachusetts’ medicaid Program, could not provide specific analysis Thursday on what the latest budget proposal would mean for its ability to cover gender-affirming care.
The state’s medicaid administrator has maintained a waitand-see approach as each iteration of proposed medicaid funding and cuts have emerged. masshealth is not pausing or ending any programs or making changes to the care it reimburses. While the federal bill remains under debate, the state agency has not received any new directives from the federal government.
“if we receive such directives, we will carefully analyze those and will communicate impacts to our plans and providers as appropriate,” a spokesperson said Thursday.
about 276,000 trans people are enrolled in medicaid nationwide, Ucla’s Williams institute school of law estimated in 2022. That’s a tiny portion of the 71.3 million medicaid recipients nationwide reported by medicaid.gov.
Targeting gender-affirming care offers the government minimal savings, but it does fit with the administration’s pattern of scapegoating the population, said nina selvaggio, executive director of the greater boston Pflag.
The impact on trans communities would likely be devastating, she said.
People who rely on hormone treatments could abruptly lose access to those drugs, potentially causing dangerous side effects and sudden changes in their appearance. a large element of gender-affirming care is not the drugs prescribed or the procedures performed, but the approach to patient care that involves cultural competence and sensitivity to the needs of trans patients.
it is unclear how changes to medicaid could prevent doctors from responding to the unique circumstances of their patients, but if such sensitivity is discouraged, it could push the trans community to be less likely to seek out needed medical care.
“ensuring that they don’t fall victim to not taking care of easily preventable diseases … that’s what gender-affirming care really is," selvaggio said.
seemingly straightforward directives in the budget proposal also could be complicated in the application. for instance, most procedures or prescriptions that could fall under the umbrella of gender-affirming care are not exclusively for trans people, selvaggio said.
a woman transitioning to become a man may seek a breast reduction or mastectomy, but so, too, could a cisgender woman concerned about her vulnerability to breast cancer or someone whose breast size is causing her discomfort. likewise, hormone blockers have medical uses beyond trans care, she said. if the proposal became law, a blanket ban on such treatments would harm people beyond the trans community, putting medicaid in the position of making case-bycase decisions for each claim that could potentially require intrusive inquiries into the personal life and sexual habits of patients.
“We’re normalizing these absurd violations of our humanity and our personhood,” she said.
Jennifer levi, senior director of transgender and queer rights at glad law in boston, said advocates were not surprised by lawmakers’ middle-of-the-night move to sharply restrict health care access for transgender people.
“it’s clearly part of this relentless attack by the administration to make transgender people’s lives impossible,” she said.
“it’s consistent with what we’ve seen rolling out from the administration and the pressure that it is putting on states and every agency of government to put tremendous barriers in the way of transgender people just living their lives.”
There have been several lawsuits challenging the rollback by some states of gender-affirming care. advocates pushing back against those restrictions at the federal district court level have seen some success, levi said. but a ruling expected in June from the Us supreme Court on an attempt to overturn Tennessee’s ban on medical gender transition treatments for minors is expected to provide more guidance.
“i’m hopeful that the courts will see these kinds of attacks for what they are, which is a desire to harm a vulnerable group,” she said. “They’re certainly not rooted in any medical science or guidelines or protocols. it’s really just a basic attack on a vulnerable group.”
Kay Lazar can be reached at kay.lazar@globe.com Follow her @Globekaylazar.
Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @ jasmlaughlin.
‘It’s clearly part of this relentless attack by the administration to make transgender people’s lives impossible.’
Jennifer levi (above, Center), Senior director of transgender and queer rights, GLAD Law