Republicans on the House Energy and Commerce Committee recently released their reconciliation bill, proposing to cut $715 billion from Medicaid. Massive cuts to Medicaid will result in millions of people losing coverage, losing access to services, and losing their health status and functioning. One of the provisions in the bill would prohibit the use of federal funding for “gender transition procedures” for persons under age 18 enrolled in Medicaid and CHIP. This prohibition would inhibit young people from receiving medically necessary inpatient and outpatient medical procedures, interventions, and medications used to treat gender dysphoria, also known as gender-affirming care. The bill would also prohibit coverage of gender-affirming care as an essential health benefit, which could limit an adult’s access to these services in both Medicaid and Marketplace plans. To justify the bill’s limitations of gender-affirming care, the updated Congressional Budget Office’s (CBO) score estimates removing federal funding of gender-affirming care for minors in Medicaid/CHIP will yield $700 million in savings over ten years.
The CBO estimate is significantly inflated. For example, in the context of lawsuit challenging Wisconsin’s coverage exclusion for gender-affirming care in Medicaid, in 2018 the State estimated that providing gender-affirming care (for adults and youth) in its Medicaid program would cost $739,000 per year, of which the federal share was approximately $443,000. See Supp. Decl. David Williams ¶ Flack v. Wis. Dep’t Health, No. 3:18-cv-00309-wmc (Oct. 16, 2018, W.D. Wis.) . This led the court in Flack to conclude that covering the excluded gender-affirming care would be “actuarially immaterial” (that is, unlikely to change costs) to Wisconsin’s overall Medicaid budget. Flack v. Wis. Dept’ Health, 395 F. Supp. 3d 1001, 1008 (W.D. Wis. 2019).
The CBO figure is also inconsistent with other estimates of the cost of care for youth, who typically use gender-affirming treatments such as puberty-suppressing medication and hormone treatment, that are relatively low-cost, running in from a few hundred dollars to approximately $4,000 per year. Another study estimated the lifetime costs of gender-affirming care as running between $25,000-$75,000 for a single individual, and noted that these costs pale in comparison to other procedures and drugs that are routinely covered by Medicaid. Studies of employer-sponsored insurance have thus consistently found the cost of covering gender-affirming care to be so low as to be “negligible.” For example, when San Francisco first began covering gender-affirming care for its employees, it added a small surcharge to partially offset the cost of the benefit; however, after 5 years, the outlay for gender-affirming care was only a fraction of the money collected through the surcharge, and San Francisco phased out the surcharge. Similarly, Colorado recently added gender-affirming care as well as other services to its EHB benchmark, a model plan that outlines the benefits that all non-grandfathered individual and small-group market plans in the state must cover. To incorporate gender-affirming care into the EHB benchmark plan, actuaries in Colorado had to certify that the added costs of covering these services was minimal, even while assuming that between 80% and 100% of all transgender individuals would use the newly available benefits.
Moreover, the CBO estimate fails to account for the costs associated with withholding care from youth who need it. Research shows that paying for medically necessary gender-affirming care is cost-effective, in part because people with gender dysphoria who are unable to access treatment for it are more likely to experience other health conditions such as depression, HIV, and substance use disorders. The research is also clear that withholding medically necessary gender-affirming care from young people can cause significant harm to their physical and mental health. In addition, people with gender dysphoria who are unable to access medically necessary care earlier in life are more likely to need more costly and invasive interventions later in their lives.
What should concern everyone is that the harm that will result from forcing young people to go without care, or in some cases, forcing them to stop care mid-stream, will cause financial and health harm. Congress’s attempt to use the budgetary process to deprive low-income people in Medicaid from accessing medically necessary health care is morally repugnant. The bill’s supposition that excluded care will save money in the federal budget is a thinly veiled guise for its true intent – the continued bullying of Transgender people, especially Transgender children. Too often, those who seek to withhold medically necessary gender-affirming services will gladly pay millions of dollars in legal fees to defend their cruel policies. NHeLP continues to affirm that gender-affirming care is good health care. We call on Congress to remove provisions from its budget proposal that would curtail federal funding for gender-affirming care.
Link to resource: https://healthlaw.org/wp-content/uploads/2025/05/119-Williams-Supp-Dec-1.pdf
