A provision in House Republicans’ “big, beautiful bill” passed Thursday would ban Medicaid from covering gender-affirming health care for transgender people of all ages, a last-minute addition to the measure with the potential to upend care for hundreds of thousands of trans Americans.
An earlier version of the bill would have also barred coverage for transition-related care, but only for minors. House Republican leadership unveiled the change and several others late Wednesday in a manager’s amendment to win over GOP holdouts to President Trump’s tax cut and spending priorities bill after days of marathon meetings across Washington.
The bill passed the House early Thursday morning in a 215-214 vote, with all Democrats and two Republicans voting against it and House Freedom Caucus Chair Andy Harris (R-Md.) voting “present.” The measure now heads to the Senate, whose Republican majority has already called for changes.
“The bans on coverage for trans medical care were made so much worse, really, in the eleventh hour of this bill,” said Caleb Smith, director of LGBTQI+ policy at the Center for American Progress. “And what a display of how it’s really not just about youth. It’s never just been about youth; It’s always been about curtailing access to medical care and bodily autonomy. All they had to do was strike ‘under 18’ from the bill, and now it’s everybody.”
States typically enjoy a good deal of discretion in determining which services are covered by Medicaid, and 10 already have policies excluding transgender-related health care, according to the Movement Advancement Project, which tracks LGBTQ state laws.
In some cases, court rulings have rendered state policies unenforceable — a federal judge struck down a Wisconsin policy excluding gender-affirming care from Medicaid coverage in 2019, and another blocked a similar policy in Florida in 2023.
Last summer, the 4th U.S. Circuit Court of Appeals said West Virginia Medicaid’s denial of coverage of gender-affirming surgery, along with a separate North Carolina policy blocking coverage for transgender care for state employees, is “obviously discriminatory.”
“There’s a wildly strong case for this to be discrimination — it is discrimination,” Smith said. “It really clearly violates equal protection because what we’re saying, essentially, is that if you are a cisgender man and you want access to testosterone, you can have it, but if you are a transgender man and you want access to testosterone, ‘Sorry, we’re not going to cover that.’”
In a statement after the bill passed the House, Rep. Dan Crenshaw (R-Texas), who introduced the provisions restricting coverage for gender-affirming care, said the prohibitions are “long overdue.”
“Gender transition procedures are the lobotomy of our generation,” Crenshaw said.
According to data collected by Smith’s group last summer, 28 percent of transgender adults in the U.S. get their health insurance through Medicaid, and 6 percent are insured through healthcare.gov or marketplace plans, meaning House Republicans’ sprawling package, which also prohibits “gender transition procedures” from being an “essential health benefit” under the Affordable Care Act (ACA), would impact roughly a third of trans adults nationwide, he said.
An estimated 276,000 transgender adults were enrolled in Medicaid in 2022, according to a report released that year by the Williams Institute, a public policy think tank in Los Angeles focused on issues related to sexual orientation and gender identity. A separate Williams Institute report published Thursday found that gay, lesbian, bisexual and transgender adults are nearly twice as likely as non-LGBT adults to have Medicaid as their primary insurance, and cuts to the program would disproportionately affect cisgender lesbian and bisexual women and trans people.
The number of transgender minors covered by Medicaid is unclear. KFF, a nonprofit health policy research, polling and news organization, estimates that Medicaid covers roughly 39 percent of children and teens in the U.S. overall.
The bill that passed the House Thursday would not prohibit ACA health plans from covering gender-affirming care outright, but it would restrict care by making it effectively unaffordable, said Lindsey Dawson, director for LGBTQ health policy at KFF.
“A health plan can cover gender-affirming care even if it isn’t an essential health benefit, but if it is not an essential health benefit, those services’ costs wouldn’t necessarily count to somebody’s out-of-pocket maximum in the plan,” Dawson said.
It is unclear how many transgender adults are enrolled in insurance through the ACA marketplace. The Department of Health and Human Services (HHS) reported in January that close to 24 million people had enrolled in coverage for the year.
The ACA requires individual and small-group marketplace health insurance plans to cover services in 10 essential health benefit categories, including emergency services, hospitalization and prescription drugs. The Trump administration has already sought to prevent plans from covering gender-affirming care, and a recently proposed Centers for Medicare & Medicaid Services (CMS) rule would, similar to House Republicans’ proposal, strike “sex-trait modification services” from being covered as an essential health benefit.
Katie Keith, director of the Center for Health Policy and the Law at the O’Neill Institute at Georgetown University, said such a move could prove confusing and burdensome for providers and lead some to possibly move away from offering care.
“What is the sort of chilling effect as you throw out more and more barriers?” Keith said.
After CMS proposed its rule in April, analysts at the Center on Health Insurance Reforms, also affiliated with Georgetown University, found through a review of public comments by industry stakeholders that “prohibiting coverage for these services for one diagnosis but not others would create significant operational burdens for insurers and headaches for many enrollees.”
CMS has also advocated in recent months for Medicaid to no longer cover gender-affirming care for transgender youth. In a letter addressed in April to state Medicaid directors, CMS Deputy Administrator and Director Drew Snyder wrote that Medicaid funds “are not to be used for gender reassignment surgeries or hormone treatments in minors.”
Professional medical organizations have said gender-affirming care for transgender adults and minors is medically necessary and strongly oppose state and federal efforts to restrict its access. Earlier this month, Trump’s HHS broke with major health groups in an unsigned report that declared gender-affirming interventions for youth lack scientific evidence.
The House-passed package also bars the Children’s Health Insurance Program (CHIP), providing low-cost health coverage to children and pregnant women in families who don’t qualify for Medicaid, from helping pay for gender-affirming care.
Some lawmakers have wondered whether the measure’s funding restrictions for trans health care violate the Senate’s “Byrd rule” preventing reconciliation measures from being used to pass “extraneous” legislation — non-budgetary items washed out in what’s called the “Byrd bath,” where the Senate parliamentarian hears arguments for and against removing possible violations.
“A number of us in the House have been talking about that: Will the Senate support its own ‘Byrd Bath’ rule?” said Rep. Becca Balint (D-Vt.). “We’ll see what happens … but I’m deeply concerned about that.”
In a statement shared Friday with The Hill, Sen. Jeff Merkley (D-Ore.), who reintroduced the Equality Act in the Senate earlier this month, called the House bill “a disaster of a budget.”
“Freedom means patients can access the range of care they find appropriate,” he said. “I’ll continue to stand with our transgender community, protect medically necessary gender-affirming care, and fight back against the Republican vision of ‘families lose, billionaires win.’”
—Updated at 2:04 p.m. EDT
