The Trump Administration Is Quietly Trying To Gut Important ACA Protections For Trans Americans

The Trump administration has quietly proposed a rule that would remove requirements that insurance providers must cover gender-affirming care as essential care on health insurance plans created by the Affordable Care Act. The practical effect would be that fewer plans would cover such care, while some states would have to shoulder the financial burden.

The proposed rule is among the changes in the Trump administration’s first major health care regulation and would have sweeping impacts across America’s health care landscape. The regulation, which sets the 2026 coverage year policies, also proposes shortening the open enrollment period, eliminating a special enrollment period for low-income families and excluding recipients of Deferred Action from Childhood Arrivals from ACA coverage.

But the proposed policy change on coverage for gender-affirming care is the first hint that the Trump administration is coming for the health care of transgender adults. Already, the Trump administration has attempted to roll back many protections for transgender people in all aspects of life. In his first few weeks in office, Trump signed a flurry of executive orders that have wrought havoc on trans peoples’ access to gender-affirming care, education, athletics and the military, and reshaped the flow of federal funding that buoys essential programs for transgender youth and adults.

On March 10, HHS and the Centers for Medicare and Medicaid Services released the proposed rule to remove what it calls “sex-trait modification” or gender-affirming care from the list of care covered by essential health benefits in insurance plans under the Affordable Care Act.

Under the ACA — signed into law by President Barack Obama in 2010 — individual and small group health insurance plans on the exchanges are required to cover care that falls into 10 categories of essential health benefits, known as EHBs. These include emergency services, maternity care, mental health, pediatric care, prescription drugs and more. In general, the package of EHBs must be “equal to the scope of benefits provided under a typical employer plan,” the law states.

The law also includes a nondiscrimination provision, known as Section 1557, which protects patients against discrimination on the basis of sex in health care settings. Former presidents Obama and Joe Biden updated the guidance to include nondiscrimination protections for gender identity, but in both terms, Trump rescinded this guidance. Most recently, his administration removed the phrase “gender identity,” in a broad effort to align agencies across the government with Trump’s executive order declaring there are “only two sexes, male and female.”

Up until now, however, many trans people on public health insurance have been able to access gender-affirming care as an essential health benefit. Currently five states — Colorado, California, New Mexico, Vermont and Washington — include coverage of gender-affirming care as part of their state’s essential health benefits benchmark plans. A total of 24 states and Washington, D.C., explicitly cover the care in state insurance plans.

“The coverage is integrated throughout the benchmark plans that states have already adopted, so it may be under a reconstructive surgery benefit or a prescription drug benefit, but it’s not some kind of special rider that you get through an insurance plan for [gender-affirming care],” said Ames Simmons, a lawyer and senior teaching fellow at Duke University School of Law.

But if this proposed rule is implemented, advocates say that the future of access to puberty blockers, hormone therapy and surgery on public plans could be in jeopardy. Plans could stop covering the benefits, and some states might choose to shoulder the costs of this coverage on their own, thereby raising the costs of health plans for consumers.

“Many insurers may drop coverage for these services or shift the costs to individuals and state,” Matthew Rose, a senior public policy advocate at the Human Rights Campaign, wrote in a statement. “This could make gender-affirming care more expensive or inaccessible for transgender individuals, particularly those with lower incomes.”

The proposal alleges that employers often do not cover gender-affirming care because few people use the benefit. In reality, transgender adults face numerous barriers to accessing insurance. Trans adults are more likely to be uninsured and report household incomes of less than $20,000 compared to cisgender adults.

Last year, HHS estimated that more than 45 million people were enrolled in a plan covered by the ACA. One estimate by the Williams Institute found that trans people make up 0.6% of the population, which could mean that at least 270,000 people could lose access to coverage for gender-affirming care.

“It’s faulty to say that no employers are covering it, and it’s faulty to say nobody’s using the coverage. I’m using it,” said Simmons, who is a transgender man using D.C.’s federal-state health program.

Employers often include coverage for gender-affirming care in their insurance plans. A quarter of large employers with 200 or more workers reported that they covered hormone replacement therapy, according to a 2024 survey of employer health benefits from the Kaiser Family Foundation.

The proposal also expresses concern with the “scientific integrity of claims made to support” the use of gender-affirming care. HHS Secretary Robert F. Kennedy Jr., who was appointed by Trump, has cast doubt on such care and peddled baseless conspiracies about transgender Americans: He has repeatedly alleged that manmade chemicals in the environment were making children gay or trans. He has also called the Biden rule aimed at preventing discrimination against trans people in health “anti-science” and has opposed young people’s access to gender-affirming care.

Decades of scientific research illustrate that access to gender-affirming treatments significantly alleviates gender dysphoria, severe depression and anxiety for transgender youth and adults alike. Many major medical associations have expressed support in access to care, particularly for youth, who face high risk of suicidal ideation.

Simmons said that the proposal is full of faulty assertions that could make it easier for LGBTQ+ advocates to challenge the rule in the courts. But Simmons said the administration’s quiet and faster-than-usual rollout of the proposed rule could signal that the administration is hoping to change policy without much oversight.

Under the Administrative Procedures Act, federal agencies are required to follow certain standards for formal rulemaking, which includes allowing the public to provide comments within 60 days of publishing the proposed rule. Agencies then review public comment and issue a final rule that goes into effect thereafter.

However, this proposed rule was first released by CMS on March 10 before it was published on the Federal Register, where the government announces changes to rules, regulations and policies, on March 19. Normally the clock starts running for people to submit public comments once the rule has been published. But the agency has given the public until April 11 to voice their opinions about the proposed rule — an expedited timeline without any explanation.

“I think they’ve sort of hinted already that they’re not interested in maximizing the public’s ability to comment on this rule,” Simmons said.

In his first term, Trump rarely paid mind to the APA — often subverting typical rulemaking processes even if it meant facing enormous pushback from the courts. Two-thirds of cases against his administration accused them of violating the APA during his first two years in office.

Federal judges have determined the administration has already violated court orders involving the freeze of federal funding, and ignored an order to turn around two planes full of migrants Trump tried deporting.