***This blog post was authored by Ian Anderson, Legal Intern, with supervision from Abbi Coursolle, Senior Attorney
As we approach the end of Pride Month, which celebrates the LGBTQI+ movement launched and sustained by Transgender women of color, Congress is considering one of the most significant rollbacks of Transgender healthcare in history. HR1 (“the bill”) is not only a massive backdoor transfer of resources to the wealthiest individuals at the expense of critical health programs, and an attack on immigrant, disabled, and low-income communities. It also singles out Transgender people for healthcare bans that would go into effect immediately on the bill’s enactment and have devastating effects on our access to essential and evidence-based medical care. Congress’s deliberation of the bill comes on the heels of the Supreme Court’s holding that a Tennessee law that banned gender-affirming care for minors in that state was constitutional, allowing the law to stay in effect and prevent Transgender youth in Tennessee from accessing medically necessary gender-affirming care.
The current version of the bill would eliminate federal Medicaid funding of gender-affirming care for Transgender people of any age. This would force states to foot the bill for such care provided through programs like Medi-Cal, at a time when the bill’s massive funding cuts are making state budget shortfalls even more severe.
Due to widespread discrimination and limited economic opportunities, Transgender people rely on Medicaid at about twice the rate of the overall population. Nationwide, the Williams Institute estimates that 12% of Transgender people are enrolled in Medicaid, compared with 7% of the overall population. Similarly, the California Health Interview Survey (CHIS) found that 2% of adults in the state who qualified for Medi-Cal were Transgender, compared to 1.1% who did not qualify. As a result, our community would be hit particularly hard by the bill’s broader attacks on access to Medicaid and Marketplace plans. These include severe coverage limits for even lawfully present immigrants, and more burdensome enrollment processes and eligibility criteria, such as work reporting requirements, that will lead to many eligible people losing coverage due to red tape. Bans on Medicaid funding to organizations like Planned Parenthood compound the harm, as these are key providers of gender-affirming care, especially in rural communities.
All told, at least 10 million people would lose coverage completely as a result of this catastrophic rollback. Based on the Williams Institute’s estimate that at least 0.6% of the US population is Transgender, and adjusted for the increased rates of Medicaid enrollment among the population, at least 100,000 Transgender people would lose coverage altogether. And access to gender-affirming care would be at risk for Transgender Medicaid enrollees across the country, of which there are at least 185,000 adults (based on Williams Institute estimates) and possibly over 700,000 total enrollees (based on Medicaid enrollment data, adjusted for Williams Institute population estimates). Based on CHIS findings, at least 160,000 Transgender Californians are enrolled in Medi-Cal.
It is especially cruel that Congress is targeting Transgender Medicaid enrollees, since they are even less likely to be able to pay out of pocket for this critical healthcare than those with private insurance. For most enrollees, even hormone therapy would represent a significant financial burden, and gender-affirming surgical care would be completely out of reach. This bill also comes in the wake of months of anti-Transgender state and federal legislation and executive orders, as well as state and federal investigations targeting providers of gender-affirming care. These attacks have already made it more difficult to locate accessible and affirming providers, and the provisions of this bill would only magnify those effects.
However, we can and should resist these attacks. This bill is not an inevitability: the Senate may make significant revisions before sending it back to the House and eventually to the President’s desk. We need to put pressure on our Senators to reverse all cuts to Medicaid and Marketplace plan eligibility and enrollment, and in particular to reject these assaults on gender-affirming care. We can also urge Senators to renew Marketplace advance premium tax credits, due to expire at the end of 2025, to ensure Marketplace plans remain affordable. Putting pressure on Senators in target states is most valuable, but even Senators who do not support Medicaid cuts need to know their constituents care about these issues. We should also contact House members, since they will have to sign off on any significantly revised version of the bill. Our time frame is limited, as Senate and House leadership have said they intend to finalize the bill by July 4.
Even if the bill goes into law without significant changes, state advocates and policymakers can take essential steps to minimize its harmful effects on Transgender Californians.
We must educate enrollees, providers, and plan administrators to ensure that no one is preemptively denied access to care. As of today, all Medi-Cal and Covered California plans must cover medically necessary gender-affirming care. Transgender beneficiaries should continue to seek care, providers should not deny care because they mistakenly think it will not be reimbursed, and plans should not deny authorization for gender-affirming services because they falsely believe they are not covered.
Secondly, we need to urge state lawmakers to step up to fund this care even if federal resources are withdrawn. Californians can contact their state representatives and urge them to commit to fully funding gender-affirming care for Medi-Cal recipients regardless of the status of federal funding. Since the California legislature is currently in budget negotiations, which have threatened other programs supporting LGBTQI+ health, this is a perfect time to share your concerns. It is also worthwhile regardless of what your representatives’ stances on transgender rights or Medi-Cal funding may be. Californian advocates and policymakers should work together with their counterparts in other states so as many as possible commit to making sure that funds are available to sustain Medicaid enrollees’ access to gender-affirming care.
Thirdly, we need to take action to fully enforce and expand state nondiscrimination regulations. California state nondiscrimination laws require plans (including all Medi-Cal plans, Covered California plans, and most private insurance plans, whether or not provided by employers) not to discriminate on the basis of sex or gender identity.
Though HR1 would create legal confusion about who is responsible for covering the cost of providing medically necessary gender-affirming care, state law is clear that California providers must continue to offer these services, and health plans regulated by California must continue to cover them. California state advocates, agencies, and policymakers should work together with their counterparts in other states to continue to enact and enforce these nondiscrimination provisions to the fullest extent. They should also increase funding for community groups and legal aid providers who can help Transgender enrollees receive the healthcare they need and deserve.
Regardless of the exact nature of the changes made to federal Medicaid and Marketplace plan provisions, we need to be clear about what state protections exist and to communicate these clearly to plans, providers, and beneficiaries alike. We must ensure that plans and providers do not mistakenly deny care through confusion or anticipatory compliance. We should provide material support to transgender communities and other marginalized groups to access the full range of necessary healthcare and the ability to thrive. This is a part of California’s history, and it has never been more necessary to do so than at the present moment.
