Medicaid Won’t Cover That: The Impact of Trans Health Coverage Bans

State governments continue to revoke access to life-saving medical care for trans people of all ages.

Erin Richards is worried that today will be the day Medicaid revokes her access to gender-affirming care. Although Ohio banned insurance for all transition-related treatments under the state’s Medicaid plan earlier this year, she has yet to receive an update from her provider confirming that coverage for her hormone replacement therapy (HRT) has been terminated. “All I know is that my prescriptions are still going through, and everything’s still covered, but I’m almost afraid to look into it,” says Richards, a 46-year-old who requested the use of a pseudonym for this story. “I’m too frightened to ask because I don’t want to trigger anything that makes someone go, ‘Oh yes, we should have cut you off by now.’”

Richards is one of countless trans Americans whose basic health care needs hang in the balance as lawmakers across the United States restrict access to gender-affirming care. Although civil rights advocates hailed a major victory in June when provisions in President Donald Trump’s One Big Beautiful Bill Act (OBBBA) banning trans Medicaid coverage across all 50 states were removed, the reality is that state governments have been rolling back access to this care for years. According to data from the progressive research group Movement Advancement Project (MAP), at least 14 states explicitly limit the treatments that trans people can receive under Medicaid, whether for minors or all patients. (That count doesn’t include Louisiana, which quietly halted Medicaid reimbursements for gender-affirming care in July.)

The GOP attacks on trans Medicaid access are highly likely to continue, in spite of recent setbacks at the federal level. According to the American Civil Liberties Union (ACLU), at least 11 other states introduced bills during the 2025 legislative session to curtail Medicaid coverage for gender-affirming care. Per the national legal advocacy group’s tracking, two have passed so far: Kentucky and Iowa. (Nine of those proposals are currently dead, while seven others are still active.) Omitted from the ACLU’s data is Richards’ home state, which prohibited trans health care under Medicaid through a back door by attaching unrelated language to a budget bill. Ohio Gov. Mike DeWine (R) signed the bill in June, on the very last day of Pride month.

Having her health care rescinded would be unthinkable for Richards, who had to leave her position as a senior consultant for a national bank in 2023 to become a full-time caregiver for her elderly mother. During a Christmas Eve visit to Richards’ family home, her mother had a devastating fall and broke her knee. After the accident, she required a wheelchair and a walker to get around. She is now predominantly bedridden and relies on Richards for everyday tasks, like bathing. 

Almost two years into their new normal, Richards feels as though her entire life has been ripped out from under her. Her 11-year-old son was forced to move in with her ex-wife, largely due to an extremely demanding caregiving schedule that initially required Richards to wake up every 45 minutes throughout the night. She and her son didn’t see one another for three months, until her mother’s health gradually improved. Having access to gender-affirming care during this tumultuous time has helped Richards withstand the many sacrifices she has made for her family’s wellbeing. Until recently, it felt like the only thing she could count on.

“Medicaid was there to cover my hormones,” Richards says. “It covered my therapy. It covered my medical care, and that kept me alive. I came very close to being hospitalized for suicide a couple of times.” She adds that she’s unsure what would have become of her without that support. “Had it not been for having access to therapy and gender-affirming care, I don’t know.”

At the State Level

Although the GOP’s war on Medicaid access affects a broad swath of Americans, trans people are uniquely impacted. Approximately one in five trans adults in the U.S. rely on the public health insurance program for their general health care needs, according to a 2022 estimate from the Williams Institute, an LGBTQ+ think tank at the University of California, Los Angeles. That figure is slightly higher than the number of adults overall who utilize Medicaid — around 15%, per the Pew Research Center. That trans Americans would disproportionately be enrolled makes sense. Medicaid is intended to assist low-income individuals, and research indicates that trans people are twice as likely as the population at large to live below the poverty line.

Under both the Biden and first Trump administrations, states were broadly expanding Medicaid access for the trans community. According to data provided directly by MAP, from January 2017 to March 2023, at least 11 states eliminated policies that had previously prevented trans youth and adults from obtaining transition-related care through the program: Alaska, Georgia, Iowa, Maine, Minnesota, Nevada, New Hampshire, Pennsylvania, Wisconsin, West Virginia, and Wyoming. 

Much like Richards in Ohio, trans people across the U.S. are deeply concerned by this sea change. Trans Iowans are experiencing a particular kind of whiplash following the dramatic reversal of rights in their state. At one time, the Hawkeye State was an unlikely leader in LGBTQ+ equality: In 2007, the state enacted a fully inclusive law banning discrimination on the basis of sexual orientation and gender identity. The following year, the Iowa Supreme Court legalized marriage equality, making the state, at that time, one of only three that allowed LGBTQ+ couples to wed.

But as America takes a hard shift to the right, Iowa’s formerly pro-LGBTQ+ policies have followed suit. In 2019, Gov. Kim Reynolds (R) approved a budget bill eliminating coverage for gender-affirming surgery under the state’s Medicaid program — which, following a years-long legal battle, was eventually struck down in court as a violation of Iowa’s civil rights legislation. But this year, Iowa Republicans struck back in a big way by gutting the very LGBTQ+ nondiscrimination law that stood in their way, thereby making the state the first in U.S. history to revoke protections on the basis of gender identity. With no remaining safeguards in place for trans people, Iowa banned coverage for trans health care under Medicaid for the second time.

Among those affected by Iowa’s newest trans Medicaid ban is Riley Shepard, 28, who had been fighting for years to finally get insurance approval for top surgery. After the original ban was struck down, things were momentarily on track: He found a surgeon and had been working tirelessly to get the procedure cleared by Medicaid. As someone who has experienced gender dysphoria since he was nine years old, Shepard says that getting that greenlight would have been the “final stepping stone to finally feeling at home” in his body. “It would make me feel complete,” he adds. “It would make me feel like the man that I am.”

In the wake of recent policy decisions, his top surgery is now on hold indefinitely. As a disabled person living on Supplemental Security Income (SSI), Shepard is currently raising funds for his surgery by selling custom T-shirts and working part-time at Spirit Halloween. He is not optimistic that he will raise enough, but his only option is to keep moving forward. Shepard says that before he transitioned, he felt as if he had spent his entire life in a dissociative state — and he cannot go back to that place.

“It’s beyond frustrating,” Shepard says. “I’ve been seeking top surgery for about six years now, and every time that it’s gotten within my grasp, it’s been yanked away from me. I’m trying not to lose hope.”

The rapid reduction in the number of states that cover trans health care under Medicaid has forced many patients to make extremely difficult choices. Emilia Stauffer, community services specialist for the GLO Center in Springfield, Missouri, says that community members in her networks “are having to choose between paying bills, getting food, and getting their medical treatments.” Stauffer’s state has been among the most vociferous in targeting trans medical care. The same year that Missouri banned gender-affirming care for patients under the age of 18, its Republican attorney general, Andrew Bailey, issued an emergency regulation to shut down virtually all trans health care in the state. The order was eventually withdrawn following the threat of a lawsuit.

Some medical providers, Stauffer says, are trying to fill the gap by providing sliding-scale treatment for individuals who have lost their Medicaid coverage. She has been directing clients to Point of Pride, a nonprofit group providing financial support for individuals in need of HRT, surgical care, or electrolysis. The Campaign for Southern Equality, meanwhile, runs the Trans Youth Emergency Project, which extends grants for families needing to travel out of state for gender-affirming care. But those resources are granted on a limited basis, and the reality is that an increasing number of trans people will go without receiving basic health care. 

Stauffer has faith, though, that her community will remain resilient in the face of immense struggle, as they have no other choice. “It’s not over,” she says. “Providers are still able to offer care. Folks are going to take care of each other, and we’re going to make sure that we’re still here.”

The National View

As lawmakers seek to limit trans Medicaid coverage at the state level, the temporary defeat in Trump’s OBBBA hasn’t prevented Republican leaders from seeking alternate routes to restrict trans health care nationally. In March, the Centers for Medicare and Medicaid Services (CMS) sent a “special alert” to federally funded health centers warning that the agency “may begin taking steps to appropriately update its policies to protect children from chemical and surgical mutilation.” (This specific phrasing is a common far-right dysphemism for HRT and gender-affirming surgeries.) At the same time, CMS proposed a new rule that will prevent states from enforcing trans-inclusive health benefits under the Affordable Care Act. The government agency also went on to demand data from hospitals that provide gender-affirming care to minors.

According to Kellan Baker, executive director of the Institute for Health Research and Policy at Whitman-Walker, the Trump administration does not intend to stop here. He says that CMS is also weighing the adoption of a new policy that would explicitly prohibit federal Medicaid reimbursement for trans youth care. If adopted, Baker says the policy would have disastrous consequences, “not just for trans young people and their families, but for any person that is seeking health care that, at any particular moment, the federal government might decide to pursue a political campaign against.”

“The federal government is vastly overreaching its authority into the personal and private healthcare conversations of families, and dictating to doctors how they treat their patients,” he says. “That is not the role of the federal government, and that is exactly what this rule is trying to impose.”

Even though federal restrictions on Medicaid coverage for transition care have yet to be adopted, some providers and medical institutions have already begun limiting the gender-affirming treatments they offer to patients. Beau Morgan, executive director for Hellbender Harm Reduction in Knoxville, Tennessee, is currently working with a local clinic where they are forced to inform patients that they can no longer be prescribed HRT — or any other form of gender-affirming care — due to Medicaid restrictions. Morgan says this clinic was “threatened with having all funding withheld if they continued providing HRT to not only minor patients, but adults as well.”

“People are really scared,” they add. “They’re scared about having to go off their medications. They’re really scared about not being able to get in to a new provider. We’ve worked really hard to fill out a referral list, but some of the clinicians have up to four-to-six-month wait periods because they’re taking on so many new transgender patients and HRT patients.”

Since the president’s second inauguration in January, hospitals in Chicago; Hartford, Connecticut; New York City; and Palo Alto, California have halted some or all forms of gender-affirming care. In July, Children’s Hospital Los Angeles (CHLA) closed its Transyouth Center, widely cited as the country’s largest provider of gender-affirming care for youth. Within hours of the CHLA clinic’s closure, the national consortium Kaiser Permanente announced that it will pause youth gender-affirming surgeries at the 40 hospitals in its network. 

In light of the national and local landscapes, trans people are doing everything they can to maintain access to medications that are, for many, life-saving. Virtually every mainstream study on the topic has shown that gender-affirming care has a profound positive impact on mental health, and reduces rates of depression, anxiety, and self-harm in trans people. In contrast, not being able to obtain transition-related health care — whether due to cost concerns, lack of insurance, or other barriers — is linked to dramatically worsened mental health outcomes, including elevated rates of suicidal ideation.

In anticipation of the day her Medicaid coverage is revoked, Richards has spent months stockpiling estrogen for future use. These days, she is intent upon staying alive. After fighting for 41 years to find herself and be the woman she wants to be, she won’t let anyone take her personhood or autonomy away from her — especially not when she has lost so much already.

“I fight for the hope that I can maybe get my life back — that I can get my career back, continue raising my kid, and get the surgeries that I want to get,” she says. “A lot of it is stubbornness. I’m not going to let these motherfuckers win.”