A transgender activist clasps her hands while Kentucky state senators vote in 2023 on a bill restricting gender-affirming care for minors. More states now are trying to limit the use of public funds for gender-affirming care for adults. (Jon Cherry | Getty Images)
While much state policy and attention have focused on restricting gender-affirming care for minors, more states now are seeking to limit such care for adults.
Lawmakers in several states have introduced bills that would prohibit Medicaid coverage of gender-transition services, prevent state or county health professionals from providing it, or bar the use of public money to pay for such care for adults who are incarcerated.
Advocates say state lawmakers have been emboldened by President Donald Trump, who has issued several executive orders and policy directives affecting transgender adults. They include ordering federal agencies to only recognize a biological, binary definition of sex; prohibiting federal money from being used to provide gender-affirming care to federal inmates; and authorizing the Pentagon to bar transgender soldiers and sailors from serving.
Gender-affirming care includes a range of services, from surgical gender-transition procedures to medication hormone replacement therapy.
Just this week, Georgia Republican senators approved legislation that would prohibit state insurance plans from covering those services. Along with Medicaid enrollees and incarcerated adults, the bill would affect employees enrolled in state insurance plans and people enrolled in public university health plans.
States that already ban access to care for youth are taking it a step further and enacting policies that impact adults.
– Christy Mallory, interim executive director and legal director at the Williams Institute
The bill “in no uncertain terms makes clear that you cannot use state taxpayer dollars, in any form, to pay for transgender surgeries,” Georgia Republican state Sen. Blake Tillery, who introduced the legislation, said on the Senate floor.
“It doesn’t say, ‘If you’re an adult you can’t have transgender care,’” Tillery said. “It says, ‘If you’re an adult, you can’t use state taxpayer dollars to have transgender surgeries.’” He added that the bill doesn’t prohibit private insurers from covering such services.
During the debate, Democratic state Sen. RaShaun Kemp held up a letter he said was signed by more than 200 doctors opposing the bill. “They’re the ones that should be making this decision. But instead, we’re telling them, ‘No, we’re going to take that power and responsibility away from you,’” Kemp said.
“Y’all — please stop,” Kemp continued.
In Kentucky, a Senate bill would prevent public money from being spent on “cross-sex hormones” and “gender reassignment surgery” for people who are incarcerated, while a House bill would prohibit health care providers from accepting payment or reimbursement for gender transition services from a state or local government or Medicare.
“We are stewards of taxpayer dollars,” the sponsor of the Senate bill, Republican state Sen. Mike Wilson, told Stateline. He added that he thinks taxpayers “do not want their money spent on sex-change surgeries, especially for criminals that are in the prisons, or the cross-sex hormones.”
The American Medical Association supports both public and private health insurance coverage for gender dysphoria treatment and “opposes the denial of health insurance based on sexual orientation or gender identity.”
But Wilson said he doesn’t “trust the AMA on certain issues.”
In Idaho, Republican Gov. Brad Little last year signed into law a bill prohibiting public money, including Medicaid, from being used on gender-affirming medications or procedures for both adults and minors.
A federal judge on Thursday blocked one of Trump’s executive orders on trans issues: a ban on gender-affirming care for those under age 19, which would force states to expand their definition of minors to 18-year-olds.
Alex Sheldon, executive director of GLMA: Health Professionals Advancing LGTBQ+ Equality, said limiting care for 18-year-olds, who are legally adults, is one way of inching closer to expanding limitations on all adults.
“We’ve seen a number of different tactics to try to expand these restrictions away from just minors and into encroaching on the rights of adults to make their own health care decisions,” Sheldon said.
Five-year trend
Since 2020, more state lawmakers have pushed legislation that would prohibit the use of state money for gender-affirming care for both minors and adults, according to the latest analysis by Movement Advancement Project, a nonprofit that tracks LGBTQ-related policies.
“States that already ban access to care for youth are taking it a step further and enacting policies that impact adults,” said Christy Mallory, interim executive director and legal director at the Williams Institute, an LGBTQ-policy research center at the University of California, Los Angeles School of Law.
Ten states — Arizona, Florida, Idaho, Kentucky, Missouri, Nebraska, Ohio, South Carolina, Tennessee and Texas — have enacted policies that explicitly prohibit Medicaid coverage of gender-affirming care for all ages, according to the Movement Advancement Project. Arkansas and Mississippi have such policies for minors. The policies in Arkansas and Florida are currently being challenged in court.
In 27 states plus the District of Columbia, Medicaid coverage of transgender-related health care is permitted, and 11 states have no explicit policy, according to the group.
Mallory said that conservative lawmakers may push for Congress “to limit care for adults to the greatest extent they can through the federal government. We just haven’t seen that come yet.”
Emboldened by Trump
Mallory and others noted that efforts to prevent public money from being spent on gender-affirming care for both adults and minors preceded Trump’s executive orders and policy directives, which face legal challenges. The changes he is seeking also would take months to officially implement, via congressional action or agency rulemaking.
But Trump’s return has added momentum to action at the state level.
“People in power are feeling really emboldened right now,” said Andrea Segovia, field and policy director of the Transgender Education Network of Texas. Segovia said her network has heard from health care providers who treat transgender adults and left the state when restrictions for minors were implemented.
Providers are facing confusion over the rapidly shifting landscape; one told Sheldon they feel as if they are stepping through “a legal and ethical minefield.” Health care systems serving transgender adults also are being affected.
A judge this week ordered the Trump administration to unfreeze federal funds, including grants used for gender-transition-related services, to comply with a previous ruling. But the freeze already has had an impact on federally qualified health centers, which are community health clinics that serve Medicaid and uninsured patients.
Jim Mangia, president and CEO of St. John’s Community Health, a network of 24 community health centers and four mobile clinics across Los Angeles, received a notice on Jan. 31 from the federal Centers for Disease Control and Prevention rescinding a $1.4 million federal grant. The letter cited Trump’s executive order that moved to end “federal funding of gender ideology.”
The health network continued essential services and eventually was able to re-access the funds. The grant pays for education, prevention, testing and treatment for transgender people at risk for HIV, Mangia said, and serves around 500 patients a year. A report from the Williams Institute in 2019 estimated that around 152,000 transgender adults are enrolled in Medicaid nationwide.
“They’re essentially dangling hundreds of millions of dollars of federal funding in front of hospitals and other health care settings, other institutions, in order to coerce them and to stop providing care for a very small population,” Sheldon said. “This is really exploiting their ability to dangle very consequential amounts of money over them to make them abide by their own political opinions on care that is not supported by any medical or legal explanations.”
Last June, Texas Republican Attorney General Ken Paxton filed a lawsuit against the Biden administration, challenging a new federal rule stipulating that under the Affordable Care Act, states cannot deny the use of public funds for gender-affirming care.
Even with the change in administration, the rule is still on the books and cannot be undone by executive order, Mallory, of the Williams Institute, explained. However, the courts will decide the extent to which the ACA prohibits gender-identity discrimination and whether that includes gender-affirming care.
Meanwhile, Segovia, of the Transgender Education Network of Texas, said her group has heard from three dozen Texas Medicaid patients who have had their care compromised as the state has beefed up enforcement of its Medicaid policy.
“We are really concerned about what this means for the future of people getting their care covered,” Segovia said. “A lot of people are just flat-out scared about what this administration is trying to do.”
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