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Marley Gotterer was recovering from surgery at home in New York when she first heard that House Republicans had passed a massive domestic policy package in the wee hours of Thursday morning.
She had prepared for nearly two years for her facial feminization surgery, a series of surgical procedures. She met with surgeons, therapists and case managers at Amida Care, a nonprofit health plan for LGBTQ+ Medicaid recipients and those living with HIV.
Her surgery, which was fully covered under Medicaid, has already made a huge difference in her life and for her mental health. She now feels an instant lightness when she sees herself in the mirror. She said she caught a glimpse of herself on a video call with friends and asked if someone had put a beauty filter on.
“I had intense gender euphoria and I felt at home in myself,” the 27-year-old comedian said. “I feel like there’s this new start in life that I’m excited about and hopeful for.”
But that hope has now been tempered.
The bill the House passed — called the One Big Beautiful Bill Act — outlines some of the largest cuts to Medicaid in U.S. history while proposing a $4 trillion tax cut for the ultra-wealthy. The bill would bar Medicaid and the Children’s Health Insurance Program from covering gender-affirming care for adults and minors alike, and would prohibit health plans offered under the Affordable Care Act from covering such care as an essential health benefit.
If the dramatic tax bill becomes law, it could jeopardize access to care for hundreds of thousands of trans adults and minors. Around 185,000 transgender adults rely on Medicaid as their primary source of health insurance, according to a report released this month by the Williams Institute at UCLA School of Law. Another study found that nearly 25% of trans adults are on Medicaid.
Research shows that transgender people are also more likely to be uninsured, underemployed and experiencing food insecurity compared to their cisgender peers, often due to high rates of employment discrimination and harassment in the workplace.
The Republican tax bill initially proposed slashing Medicaid coverage for gender-affirming care for minors only. But hours before the final vote, House Republican leadership issued 42 pages of amendments with last-minute changes, including striking the phrase “for minors” from the ban on transition coverage under Medicaid, effectively extending it to people of all ages.
The bill could also codify changes to the Affordable Care Act that the Trump administration first unveiled in March. At the time, the White House issued a rule change for the Centers for Medicare and Medicaid Services that would remove gender-affirming care from the list of essential health benefits in insurance plans.
Under the ACA, which President Barack Obama signed into law in 2010, health insurance plans are currently required to cover care that falls into 10 categories of essential health benefits, including emergency services, maternity care, mental health, pediatric care and prescription drugs.
All together, this omnibus bill’s changes to Medicaid and the ACA could have a significant effect on hundreds of thousands of trans adults in the U.S. and an unknown number of trans youth. The Senate is expected to make some major changes to the bill by July, but LGBTQ+ advocates don’t foresee Republican senators backtracking on the provisions related to transgender care.
Currently, Medicaid programs in 27 states and the District of Columbia have policies that explicitly include coverage for transgender-related health care, according to the Movement Advancement Project.
If President Donald Trump signs some version of this bill into law, it would force states to shoulder the cost of coverage for trans health care, said Ames Simmons, a lawyer and senior teaching fellow at Duke University School of Law.
But given the scope of the bill’s other cuts — including to the Supplemental Nutrition Assistance Program — Simmons is not optimistic that states would be able to help recoup all of these social safety nets.
“If we think broadly about trans people being more likely to be low-income for many reasons, like histories of employment discrimination, which if you don’t have a job in our country, it’s harder and more expensive to get health insurance,” he said.
“I think it’s not at all a realistic option to think that trans people who are no longer able to get Medicaid coverage for the treatment of gender dysphoria would easily be able to find coverage elsewhere on the private market,” he added.
Honey Pluton, a 31-year-old trans man and bartender in New York City, said he can’t wrap his head around what it would mean to lose access to his hormone therapy, which he now gets through Medicaid.
“I don’t even know how much it would cost a month,” he said, noting that he would do whatever he could to ensure that he could continue care. “Thinking about adding another expense seems intimidating outside of how it impacts me financially. It’s just an existential threat.”
Beyond specific cuts to gender-affirming care, the bill also takes aim at Planned Parenthood and clinics that provide abortion care. This could spell trouble not only for patients seeking abortions but for trans and nonbinary patients who use Planned Parenthood’s transgender care services.
In 2021, over 35,000 patients sought hormone replacement therapy at Planned Parenthood locations nationwide, Dr. Bhavik Kumar, the medical director of primary and trans care at Planned Parenthood Gulf Coast, told NPR.
Since returning to office in January, Trump has taken many steps to curtail trans people’s access to gender-affirming care. Within the first few weeks of his presidency, he signed an executive order announcing the government will only recognize two immutable sexes, barred trans women and girls from playing on female sports teams, blocked trans people from serving in the military, and threatened to pull millions of dollars in federal funding from hospitals and organizations that serve LGBTQ+ people and people living with HIV.
Dr. David Johns, the executive director of the National Black Justice Collective, called the new GOP tax bill a calculated effort to try to erase trans people from public life.
“The same bill slashes Medicaid and SNAP benefits, guts civil rights and disability enforcement, and strips millions of Americans—disproportionately Black, Brown, poor, disabled, and queer—of access to basic health services,” Johns said in a statement. “This isn’t about fiscal responsibility. It’s about using trans lives as a political wedge to force through a budget that serves billionaires and punishes the most vulnerable.”