Access to gender-affirming care for transgender youth will be dramatically restricted by the Trump administration under new proposals by the Department of Health and Human Services.
NPR has obtained the draft text of a proposed rule that would prohibit federal Medicaid reimbursement for medical care provided to transgender patients younger than age 18. It also prohibits reimbursement through the Children's Health Insurance Program or CHIP for patients under age 19.
An additional proposed rule would go even further, blocking all Medicaid and Medicare funding for any services at hospitals that provide pediatric gender-affirming care.
The rules are being prepared for public release in early November, according to an employee at the Centers for Medicare and Medicaid Services. The employee asked that NPR not use their name because they fear professional retribution for speaking to the media without authorization. An HHS spokesperson did not respond to a request for comment about the planned timing of the proposed rules' release.
A near ban in all states
Both supporters and opponents of transgender rights agree that, taken together, the forthcoming rules could make access to pediatric gender-affirming care across the country extremely difficult, if not impossible. The care is already banned in 27 states.
"These rules would be a significant escalation in the Trump administration's attack on access to transgender health care," says Katie Keith, director of the Center for Health Policy and the Law at Georgetown University.
"I think it's really, really important to note that nothing is changing immediately," she explains. "These would be proposals that would go out for public comment, it would take months for the Trump administration to issue a final rule, and then, if past is prologue, we would see litigation over whatever the final rules are."
Administration goals
In his first days in office, President Trump signed an executive order declaring that the United States "will not fund, sponsor, promote, assist, or support the so-called 'transition' of a child from one sex to another."
In the months since, HHS released a report critical of the research that supports access to this care. A federal suicide prevention lifeline specifically for transgender youth was cancelled, as were hundreds of millions of dollars in scientific research funding related to LGBTQ people. Federal health officials warned state Medicaid directors to tread carefully, and the Department of Justice announced subpoenas of some children's hospitals and threatened providers with prosecution.
"I think these restrictions are very good," says Terry Schilling of the forthcoming rules. Schilling is president of the American Principles Project, a conservative advocacy group. "It's going to change the entire transgender industry, and it's going to take away a lot of their funding streams."
He points to an opinion poll from the spring, which found 66% of the public opposes Medicaid coverage for this type of care for young people.
"They believe that if you want to get some type of sex-trait modification procedure, you should have to pay for it," Schilling says. "The American people are fully behind this effort."
Dramatic new expansion of power
The proposal to condition a hospital's participation in Medicaid and Medicare on halting gender-affirming care for youth represents an "unprecedented" use of the executive branch's power to control what medical care is available in hospitals, says Keith.
"Because Medicare is such a significant portion of many hospitals' revenue," she explains, the rule would essentially force hospitals to end their gender care programs for transgender youth. That would mean all of those programs' patients — whether they have Medicaid or private insurance — would lose access.
This is not how the federal government normally uses this type of rule, Keith says. She served in the Biden administration on the Gender Policy Council, and worked on some "conditions of participation" regulations for Medicare and Medicaid, she says. "They're so basic — it's like, you have to have a crash cart [with] enough medicine to help a pregnant woman in crisis."
Instead of health and safety standards, this proposal would instruct hospitals "to stop offering a certain type of care completely to a certain patient population," she says.
Law professor Katie Eyer of Rutgers University questions whether such a rule would survive a court challenge. "But if it were successful, I shudder to think what this administration would do with such a tool in their hands," she says. It could open the door for any White House to withhold all federal funding from hospitals over the provision of medical care that it disfavors.
"The writing has been on the wall that this has been coming," says Lindsey Dawson, director of LGBTQ Health Policy at KFF, a nonpartisan health research organization.
Yet the timing of the release has been a mystery for months. Notice of both proposed rules — though not the rules themselves — appeared on a government register over the summer, and it's been unclear why they have yet to be released, Dawson says.
'An obsessive focus'
The administration's efforts on transgender issues stretch far beyond health policy and beyond youth. The Federal Trade Commission recently hosted a workshop "on unfair or deceptive trade practices in 'gender-affirming care' for minors." The military forced out transgender servicemembers. Universities have been told their federal funding is contingent on adopting anti-transgender policies on issues like bathroom access.
Even the impending lapse in funding for food assistance, or SNAP, is linked to Democratic support for "gender mutilation procedures," according to a banner on the Department of Agriculture website.
"It's endless," says Eyer. "It really has been an obsessive focus that's been deployed across the administration."
The warning letters and cancelled grants and more have had a significant chilling effect. In the states where the care is still legal, many clinics and hospitals have ended their programs for gender-affirming care. If these rules were to take effect, the remaining programs would likely follow suit.
"There are real people behind all this," says Eyer, who is also the parent of a transgender child. "People are really scared and suffering as a result of this onslaught of attacks on the trans community."
It's still legal, although access is shrinking
Gender-affirming care for youth — including puberty blocking medications, hormones, and rarely, surgery — does not actually violate federal law, Eyer notes. And, despite recent political pressure, no major U.S. medical organization has altered their clinical guidance that supports these treatments as appropriate and safe.
Approximately 3% of youth in the U.S. identify as transgender or nonbinary, although not all of them seek medical treatment related to their identity.
Notably, in Utah, a state-commissioned analysis of the evidence recently came to the opposite conclusion as the Trump administration's transgender report. University of Utah researchers found that there was ample evidence of benefits and safety for these treatments, and wrote that policy restrictions on this care for youth "cannot be justified based on the quantity or quality of medical science findings or concerns about potential regret in the future."
The draft text of the proposed federal rule obtained by NPR does not mention the Utah analysis, nor does it cite the American Academy of Pediatrics, whose guidelines also support access to the care.
In Eyer's view, the public release of these rules will offer the opportunity for them to be legally challenged.
"It will be subject to 'arbitrary and capricious' review, and a court will presumably take a close look at the factual basis that actually underlies it," she says. "That is actually preferable to what we've had up until now, which is coercion without law."
Diane Webber edited this story.
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