Illustration: Annelise Capossela/Axios
A provision in the House-passed reconciliation bill would be another step toward a long-term GOP goal of eliminating federal funding for transgender health care — a goal that tracks with principles laid out in the Heritage Foundation's Project 2025.
Why it matters: If the provision survives intact, the reconciliation package would become the second major federal law with gender-affirming care restrictions.
What's inside: The bill would ban federal funds from being used for gender-affirming care in Medicaid and CHIP after lawmakers made a late change to the draft and expanded the prohibition to both youths and adults.
- It comes after Congress added restrictions to last year's defense authorization bill that banned the military from covering surgeries for transgender troops and paying for gender-affirming care for servicemembers' dependents.
- A key question is whether the latest provision will survive the "Byrd bath" when the Senate takes up the reconciliation bill, or if it's deemed out of order because it's unrelated to the budget.
State of play: A manager's amendment released just hours before the reconciliation package went to the House floor last week expanded a proposed ban on federal Medicaid funds being used to pay for puberty blockers, hormone treatment and surgery so that it applies to both minors and adults.
- Medicaid payment policies vary by state, and some have imposed similar restrictions, several of which are the subject of litigation, per KFF.
- The reconciliation bill also has implications for ACA coverage of gender-affirming care because it prohibits health plans from covering "gender transition procedures" as an essential benefit beginning in 2027.
Between the lines: Some have likened the step-by-step defunding measures to Hyde Amendment prohibitions on abortion funding that date to the 1970s and have become a standard part of the appropriations process.
- The Human Rights Campaign said that last year's defense bill marked the "first anti-LGBTQ+ federal law enacted since the Defense of Marriage Act in 1996."
- "Any restriction of health care for the trans community … would be devastating, but especially the wide reach of this will impact so many Americans," said Tyler Hack of the Christopher Street Project, a transgender advocacy group.
Alongside the Hyde Amendment, the GOP-led House's Labor-HHS appropriations bill for FY25 included a rider that banned federal funds for "social transitioning, or for drugs or surgery that alter bodily sex traits."
- But that language wasn't included in several continuing resolutions that kept the government funded since.
- Rep. Marjorie Taylor Greene also has been unsuccessfully pushing for action on her bill that would criminalize providing gender-affirming care to minors.
The Trump administration is moving administratively with its own restrictions across agencies.
- The VA is phasing out covering gender-affirming care for veterans. The Bureau of Prisons was also directed to stop providing gender-affirming care for federal inmates.
- On Wednesday, HHS sent a letter to health care providers and state medical boards that said they should update treatment protocols around gender-affirming care based on the agency's review of the treatments that it found have "weak evidence of benefit" and "risk of significant harms."
- CMS followed that up with a letter sent Wednesday to hospitals requiring them to provide information on the gender-affirming care procedures provided to minors at their facilities.
By the numbers: More than 185,000 transgender adults use Medicaid as their primary insurance, per recent data compiled by the Williams Institute at the UCLA School of Law.
- LGBT individuals are also twice as likely as non-LGBT adults to have Medicaid as their primary insurance, according to the Williams Institute.
The bottom line: With Republicans maintaining that the federal government shouldn't pay for gender-affirming care, advocacy groups say those already receiving treatment will be deeply affected if funding is cut off.
- "This includes folks who have been on their gender-affirming care for 10, 20, 30, 40, 50 years," said Hack of the Christopher Street Project.
