The Women’s* Health Defense Table (W*HDT) is a national coalition of organizations working together to defend equitable access to affordable, comprehensive, discrimination-free, and high-quality health care delivered with dignity and respect, and in particular sexual and reproductive health care, for women (including transgender, queer, and intersex women) and nonbinary people. Beginning with our defense against efforts to repeal-and-replace the Affordable Care Act (ACA) starting in 2016, W*HDT has provided national leadership in federal efforts to defend Medicaid and the ACA against fundamental threats on behalf of women and nonbinary people, and especially people with low incomes and from underserved communities. This work informs the undersigned organizations’ deep concerns regarding how and why the policies outlined in Project 2025, a 920-page agenda “for the next conservative administration” (Project 2025 at xiii), place women and nonbinary peoples’ health in peril, especially among those with low incomes and underserved communities such as Black, Indigenous, and people of color, people with disabilities, immigrants, LGBTQI+ people, and young people. In this joint statement, we focus on Project 2025’s threats to Medicaid, the ACA, and related civil rights laws and policies.
I. Project 2025 would eviscerate health insurance coverage, including sexual, reproductive, and gender-affirming care coverage, for millions of women and nonbinary people in Medicaid
Project 2025 proposes numerous cuts to the Medicaid program, our country’s largest health insurance safety net for women and nonbinary people. Medicaid provides health insurance to 73.9 million people in the U.S., roughly 26% of whom are women or gender-expansive people assigned female at birth who are of reproductive age, and finances 41% of U.S. births. Project 2025 seeks to change Medicaid’s financing mechanism through reforms such as turning Medicaid into a block grant program or imposing per capita caps (466), which policymakers have historically proposed to severely cut Medicaid funding to states. Although nearly all Medicaid enrollees who can work do so, Project 2025 recommends allowing states to impose work reporting requirements (467–468), which would push millions of people with low incomes, including low-wage workers, out of coverage. Extensive research shows that many people who qualify for exemptions to work requirements, such as people with disabilities and pregnant people, are nevertheless denied access to them. Further, Project 2025 would impose time-limits on how long people can receive Medicaid coverage during their lifetimes (468). It would allow states to reform asset tests (467), which discourage savings among people concerned with losing benefits and impose burdensome paperwork verifications. Project 2025 also proposes to allow states to make unilateral changes to their Medicaid programs without waivers or state plan amendments, and thus, without federal oversight or public comment (468–469). This could allow harmful policies that harm women and nonbinary people in Medicaid to proliferate.
Criticizing Medicaid’s incentives for states to expand coverage to people with low incomes, Project 2025 also proposes replacing enhanced federal matching funds with a “more rational match rate” (466–467). Historically, those ideologically opposed to Medicaid attempted to reduce funding for the program by pursuing cuts to federal financial medical assistance percentages. This change may push states to abandon optional coverage categories such as Medicaid expansion, which has improved access to sexual, reproductive, and gender affirming care, reduced maternal mortality, and narrowed health inequities for millions.
If implemented by the next administration, Project 2025 would likely gut Medicaid access to family planning services and supplies. It recommends adding “flexibility to eliminate obsolete mandatory and optional benefit requirements” (468). This could prompt states to end or severely reduce Medicaid coverage for family planning services and supplies, among other current mandatory benefits (468). Project 2025 would also force state Medicaid programs to make an impossible choice between participating in an expanded CDC abortion surveillance program that would likely be used to criminalize pregnant people — particularly immigrants, Black, Indigenous, and other people of color, young people, and people with disabilities — or losing their federal funding for Medicaid family planning services and supplies (455–456).
As part of an overarching strategy of using federal authority to end abortion access across the country, Project 2025 proposes to permanently codify the Hyde Amendment’s severe restrictions on abortion coverage in Medicaid and other federal programs (474), criminalize medication abortion nationally through the Comstock Act (562), and federally recognize fetal personhood (6). Drawing on an overbroad interpretation of the harmful Weldon Amendment, Project 2025 would end federal Medicaid funding for states that require abortion coverage in private insurance (472, 493), and permanently codify the Weldon Amendment (474). Further, it would end Medicaid funding for Planned Parenthood, nearly half of whose patients access services through Medicaid (471). This would likely have repercussions for other sexual and reproductive health care providers as well.
Project 2025 also includes a series of proposals that would severely limit access to gender-affirming care, which is evidence-based, essential, lifesaving health care and a required Medicaid service. These include increasing barriers to care for youth (333), advancing anti-transgender pseudoscience (491), and ending gender-affirming care access in the Ryan White HIV/AIDS Program (485), which serves many people with HIV with low incomes who fall into Medicaid coverage gaps.
II. Project 2025 would end critical ACA and related civil rights protections for women and nonbinary people
Project 2025 aims to police sex and gender, define the “right” kind of family for everyone, and promote anti-LGBTQI+ pseudoscience that seeks to invalidate the existence of transgender and nonbinary people. To execute these aims, Project 2025 proposes rolling back the U.S. Department of Health and Human Services’s (HHS) 2024 final rule clarifying nondiscrimination protections under Section 1557 of the ACA (475). In particular, the plan recommends eliminating provisions that clarify protections against sex discrimination (e.g., gender identity, sexual orientation, pregnancy or related conditions, sex stereotypes, and sex characteristics, including intersex traits) (495–496). Without these regulatory provisions, discrimination related to sexual, reproductive, and gender-affirming care would likely proliferate. The policy agenda also recommends restoring prior regulations on Section 504 of the Rehabilitation Act, which prohibits disability discrimination (495). Earlier this year, HHS finalized robust reforms to these regulations for the first time since 1977. The new final Section 504 rule provided critical and long-overdue updates to strengthen protections against disability discrimination in programs and services that receive HHS funding, including in a sexual and reproductive health context. Project 2025 also proposes broadening exemptions from the ACA’s no-copay contraceptive mandate for employer-sponsored health plans (483), which would increase barriers to contraceptives around the country.
Project 2025 recommends reissuing a 2019 Final Rule that gutted the ACA’s modest protections for people to access abortion coverage (473). Doing so would essentially make the ACA’s provision on abortion coverage meaningless, with devastating effects on health and economic futures. Project 2025 also conflates abortion and emergency contraception (485), and proposes eliminating coverage of emergency contraception from the ACA’s contraceptive mandate (485). Further, the agenda includes proposals that aim to undermine the ACA’s women’s preventive services mandate, which requires most health plans to cover recommended preventive services without cost-sharing, by removing evidence-based recommendations and restoring ideologically driven recommendations from the past (484–485).
Conclusion
This joint statement provides a snapshot of the ways in which Project 2025’s proposals could do immeasurable harm to women and nonbinary people’s health care access. Defending Medicaid and the ACA from the policies in this agenda is a gender equity and sexual and reproductive health, rights, and justice imperative. We call on the next administration — regardless of partisan or ideological makeup — to reject these dangerous proposals.
Co-Signing Organizations
#AccessBetter Disability Sexual and Reproductive Health Education
All* Above All
Center for Reproductive Rights
Center on Reproductive Rights and Justice at UC Berkeley Law
Community Catalyst
Families USA
Guttmacher Institute
In Our Own Voice: National Black Women’s Reproductive Justice Agenda
Ipas
Jacobs Institute of Women’s Health
National Abortion Federation
National Asian Pacific American Women’s Forum (NAPAWF)
National Health Law Program
National Institute for Reproductive Health
National Latina Institute for Reproductive Justice
National Women’s Health Network
National Partnership for Women & Families
National Women’s Law Center
Physicians for Reproductive Health
Planned Parenthood Federation of America
Positive Women’s Network-USA
Power to Decide
Reproductive Freedom for All
The Century Foundation Maternal and Reproductive Health Team
URGE: Unite for Reproductive & Gender Equity
Reporters interested in learning more or speaking with the W*HDT co-chairs should contact NHeLP’s Director of Communications, Andy DiAntonio, at [email protected].
