An early version of House Republicans’ “big, beautiful” bill of President Donald Trump’s tax and spending priorities proposed eliminating federal Medicaid funding for gender-affirming health care for minors alone.
But in last-minute amendments, the provision changed to apply to transgender adults, too.
“Trump’s ‘Big, Beautiful’ reconciliation bill will yank lifesaving medical care for 150,000+ trans adults on Medicaid,” Media Matters for America’s Ari Drennen wrote May 21 on X. Drennen is the LGBTQ+ program director at the left-leaning organization, which monitors conservative media.
On her post, Drennen attached screengrabs of the legislative change. One image showed the section’s original title: “Prohibiting Federal Medicaid and CHIP Funding for Gender Transition Procedures for Minors.” The second image showed a portion of a May 21 amendment from Rep. Jodey Arrington, R-Texas, that struck “for minors.”
The change was one of many the House Rules Committee made to garner enough Republican votes to pass the bill along party lines May 22.
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Some celebrated the change: “The original bill’s ban on Medicaid dollars for transgender care for children has now been expanded to also prohibit it for adults,” the House Freedom Caucus posted on X after the bill’s House passage. The House Freedom Caucus is one of the most conservative and pro-Trump blocs in Congress.
The Senate is considering the bill. In its current form, it would prohibit federal Medicaid funding from being used for gender-affirming medical care. The Congressional Budget Office analyzed the policy when it applied only to minors, finding the provision would save $800 million dollars over 10 years, but it has yet to update its analysis to include adults, so it’s not exactly clear how many people could be affected.
Medicaid is a federal-state program that provides health insurance coverage to 83 million low-income and disabled Americans. It distributes matching federal funds to states to supplement health care spending, but beyond federal minimum requirementsstates have flexibility to decide coverage. Some states cover gender-affirming medical care. Others do not.
The GOP-backed bill would implement a blanket policy that federal funds could not be used to cover gender-affirming surgeries, cross-sex hormones or puberty blockers when used for the purpose of transitioning to a different gender. Patients who need those treatments for other purposes, such as pausing early-onset puberty, would still have access.
How many transgender Americans would be affected by this proposed change?
Although several non-governmental surveys shed light on how many transgender adults receive Medicaid, we don’t know how many receive it specifically for the purpose of receiving gender-affirming care.
A May 2025 report from the Williams Institute, an LGBTQ+ public policy research institute at UCLA, found that 12% of transgender adults used Medicaid as their primary source of health insurance. That’s almost twice as high as cisgender Americans — people whose gender identity matches the sex they were assigned at birth — and equals about 185,000 people. Previous Williams Institute reports in 2019 and 2022 estimated 152,000 and 276,000 trans adults were enrolled in Medicaid, respectively.
A 2023 survey by KFF, a health policy think tank, found 21% of transgender adults had insurance through Medicaid.
But not all trans Medicaid enrollees would be affected by the bill’s revocation of federal funds. For one, not all trans people seek gender-affirming medical care.
Plus, according to the Movement Advancement Projecta nonprofit think tank that tracks LGBTQ+ policies, 13 states already exclude Medicaid from covering gender-affirming medical care. In 10 states, the exclusions involve adults and minors; in three, the restrictions are limited to minors. That means 28% of LGBTQ+ adults already live in states where Medicaid coverage excludes gender-affirming care.
But many others do use Medicaid to cover care. In a study of 48,000 patients from 2016 to 2019 who underwent gender-affirming surgery, 25% were Medicaid recipients. And 58% of the LGBTQ+ population live in 27 states where transgender-related health care is explicitly covered by their state’s Medicaid program. The remaining 14% live in states with unclear or nonexistent policies.
The bill’s provisions would affect trans people with private insurance, not just Medicaid. One measure would prohibit insurance plans sold on Affordable Care Act marketplaces from considering gender-affirming care as an “essential health benefit,” which has additional consumer protections.
Lindsey Dawson, KFF’s LGBTQ+ health policy director, said the bill would not prohibit states from covering gender-affirming care if using state-only funds.
“However, states are already facing tight fiscal environments and enactment of the reconciliation bill could strain those budgets further,” Dawson said. “States will be forced to make tough decisions about what services they can cover.”
States navigated a similar situation with abortion. The Hyde Amendment, attached to the U.S. Department of Health and Human Services’ budget since 1976, prohibits using federal Medicaid funds to cover abortion, except in limited circumstances such as rape, incest or life of the mother. But some states continue to offer coverage using state funds.
Christy Mallory, the Williams Institute’s interim director, said states may be able to provide gender-affirming care without federal funding if the bill passes, “but in practice, it’s actually generally thought of as a ban.”
This provision specifically addresses funding, but would be implemented alongside other policies from the Trump administration aimed at restricting access to gender-affirming care, said Kellen Baker, executive director of Whitman-Walker’s Institute for Health Research & Policy, which focuses on LGBTQ+ issues. Whitman-Walker sued the first Trump administration over its trans health care policy.
Baker called the Medicaid provision part of “a pattern of harassment, intimidation and threats of prosecution with the intended goal of making it politically, financially or legally impossible for states to cover this care, for providers to offer it and for transgender people to access it.”
Legal challenges are expected. In the past few years, federal courts have struck down state Medicaid policies restricting coverage of gender-affirming medical care, including in Wisconsin, North Carolina, West Virginia and Florida. The Affordable Care Act has an anti-discrimination provision that some have used to challenge similar state policies.
