The U.S. House of Representatives has passed a sweeping Republican-led budget reconciliation package — dubbed the “Big Beautiful Bill” by President Donald Trump and the bill’s proponents — that, if enacted, would decimate access to gender-affirming care for transgender people of all ages across the country.

More than a tax bill, the legislation, passed 215-214 in the early morning hours Thursday, couples tax cuts for corporations and the wealthy with profound structural changes to Medicaid and the Affordable Care Act, including provisions that would strip transgender people of access to transition-related care — even when privately insured. It’s a vision of health policy that experts told The Advocate weaponizes bureaucracy and budgetary authority to target one of the most marginalized groups in the country.

What Trump’s budget bill does to trans health

At the heart of the bill are two key provisions targeting transgender health care. The first prohibits Medicaid and the Children’s Health Insurance Program from covering any gender-affirming services — puberty blockers, hormone therapy, surgeries — for people of any age. The second redefines what counts as an “essential health benefit” under the ACA, explicitly excluding transition-related care from private insurance plans regulated by federal standards.

Katie Keith, a scholar and director of the Center for Health Policy and the Law at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center, told The Advocate the bill would “certainly increase health care costs for transgender people, both on those who have Medicaid coverage, but also those who have marketplace coverage as well.”

“By stripping federal funding for treatment for gender dysphoria, you’re imposing a whole set of barriers,” she said. “A primary one is cost. But I think it will also have the unintended — or maybe intended — consequence of deterring providers from offering this care at all.”

Keith, who previously served as deputy assistant to the president and deputy director of the White House Gender Policy Council under President Joe Biden, added that the essential health benefits provision could destabilize health coverage even for those outside ACA marketplaces. 

“By proposing to exclude treatment for gender dysphoria from essential health benefits, this care would not be subject to cost-sharing limitations that apply to essential health benefits under the Affordable Care Act,” she explained. “If treatment for gender dysphoria is not considered an essential health benefit, transgender people — including those in job-based private health insurance — could face higher out-of-pocket costs for care that would otherwise be covered.”

Medicaid cuts and their fallout

The bill’s language goes beyond cost containment; it reengineers Medicaid to eliminate federal support for gender-affirming care, even in states that affirmatively cover it. As Adrian Shanker, a former Biden administration LGBTQ+ health adviser in the Department of Health and Human Services, told The Advocate, this would deliver a disproportionate blow to low-income trans people who rely on Medicaid

“Medicaid is the payer for low-income Americans, and it’s an essential safety net program,” Shanker said. “We know that trans people are disproportionately lower income and benefit from Medicaid in a higher percentage than the majority population. We know that’s even more pronounced among trans people of color and trans people who are from rural communities.”

A new study from the Williams Institute at UCLA underscores the scale of what’s at stake. Drawing on federal health data, the May report finds that approximately 1.8 million LGBTQ+ adults — nearly twice the rate of non-LGBTQ+ adults — rely on Medicaid as their primary source of health insurance. The burden is especially acute among transgender people, more than 185,000 of whom depend on Medicaid. These disparities, the authors note, are driven by intersecting inequalities — including disability, parenting responsibilities, and systemic economic disadvantage — that make Medicaid a lifeline for some of the most vulnerable in the LGBTQ+ community.

The bill would, in effect, force states to either self-fund gender-affirming care or deny it outright — something most budgets could not absorb.

The legislation’s ripple effects would be especially catastrophic in states like Colorado, where budget constraints enshrined in the state constitution limit how leaders can respond to sudden federal funding shortfalls. Mardi Moore, executive director of Rocky Mountain Equality, told The Advocate that Colorado’s unique combination of a balanced budget requirement and the Taxpayer’s Bill of Rights (TABOR) would make it nearly impossible for the state to backfill the $10 billion the state receives annually in federal Medicaid funding.

TABOR, adopted by voters in 1992, is one of the most restrictive fiscal policies in the country. It caps state spending increases to a formula based on population growth and inflation — but inflation as experienced by government services, not consumers, Moore explained. TABOR also requires voter approval for any new taxes or tax increases, which means Colorado’s legislature cannot simply raise revenue or allocate extra funds to offset lost federal support without a ballot measure.

“The service gaps are going to widen, especially for LGBT communities, people of color, rural communities, low-income folks, and young people,” Moore said.

Why the bill targets trans health

The bill’s framing — slashing Medicaid to “pay” for tax cuts while targeting trans care — represents what critics have called a cruel calculus: appealing to a political base through culture war flashpoints. “This administration seems obsessed with the idea that their political goals are more important than the health and wellbeing of the American people,” Shanker said.

Moore, a longtime LGBTQ+ advocate, echoed that sentiment. “They know this is a winning issue for their base,” she said of the bill’s anti-trans provisions. “Our movement has not done a great job of getting information out about trans folks. The narrative that gender-affirming care is a choice and not medically necessary has taken hold. ‘Why should my tax dollars pay for your choice?’” she said. “That’s what we’re fighting.”

Related: Trump administration announces end to gender-affirming care for transgender veterans

Even if the bill dies in the Senate, Moore argued that the damage has already been done. “The national narrative is starting to take hold in Colorado,” she warned. “There’s just not enough of us who care about others to make the community well.”

A broader strategy of erasure

Advocates for Trans Equality, the largest trans-led policy organization in the U.S., called the bill a calculated political attack. “This budget proposal is a direct, calculated attack on the lives and dignity of people across the country,” Sinead Murano-Kinney, the group’s health policy analyst, said in a statement. “These cuts clearly aim to make trans people and their healthcare into political scapegoats.”

Murano-Kinney pointed to a 2022 Williams Institute report showing that 21 percent of trans adults rely on Medicaid, likely due to high rates of employment discrimination and economic instability. “Denying access to this care would not only worsen physical and mental health outcomes but would deepen housing insecurity, exacerbate mental health crises, and increase rates of depression and suicidality among trans people.

Related: Why do inmates have access to gender-affirming care? Those Trump ads you keep seeing debunked

“This is no accident — it is part of a broader political agenda driven by anti-trans extremists determined to force trans, nonbinary, and intersex people out of public life,” she added.

Insurance industry raises alarm

Notably, even the health insurance industry has balked at the logistical and financial burdens of carving out gender dysphoria care from essential health benefits. In public comments reviewed by the Center on Health Insurance Reforms at Georgetown, insurers such as the Blue Cross Blue Shield Association warned that banning care for gender dysphoria would create “significant operational burdens” and could inadvertently disrupt access to services used for other conditions, including cancer treatment, menopause care, and birth control procedures like vasectomies.

“This is just health care,” said Keith. “Many of these procedures are medically necessary for cisgender people, too. The only difference is who’s receiving the care.”

What comes next?

Keith said legal challenges are inevitable, but the immediate policy impact is clear: health care for most transgender Americans is at risk.

Related: Trump signs executive order banning federal support of gender-affirming care for anyone under 19

The Congressional Equality Caucus has condemned the bill, with Chair Rep. Mark Takano of California warning that 13.7 million Americans will lose their health insurance if it becomes law. “Attacks on the trans community are just the cherry on top,” Takano said. “Congress should be working to make healthcare more affordable — not banning medically necessary care or pulling the rug out from underneath millions who rely on Medicaid.”

The stakes are no longer hypothetical as the bill heads to the Senate. 

“The word I just use over and over is cruel,” Moore said. “How much more cruel can you be, and what’s the point of this? Is the point really cruelty?”