Public Health and Ethical Risks of Rollbacks on Medicaid Coverage for Gender-Affirming Care

Gender minority individuals experience substantial mental health disparities compared with cisgender people. Gender dysphoria, a psychological distress stemming from incongruence between an individual's gender identity (eg, man, woman, nonbinary) and sex assigned at birth (ie, male, female), significantly contributes to these disparities. Gender-affirming care, including hormone therapy and surgical interventions, is the leading recommended treatment for gender dysphoria. Gender-affirming care modifies sex characteristics to align with an individual's gender identity, with the aim of alleviating distress. Major medical organizations, including the American Medical Association, endorse gender-affirming care as medically necessary.

Despite this consensus, a sweeping federal bill passed by the House of Representatives in May 2025 proposes to eliminate all federal funding for gender-affirming care under Medicaid and the Children's Health Insurance Program (CHIP), effective January 2027. This legislation would prohibit states from using federal funds for gender-affirming care for individuals of any age, threatening access for the hundreds of thousands of gender-minority individuals enrolled in Medicaid and CHIP in the US. By targeting medically necessary care, this rollback endangers the mental health of gender minority individuals and the ethical obligations of clinicians.

This proposal follows mounting state-level restrictions. As of 2025, approximately half of US states have enacted laws banning gender-affirming care for adolescents and, in June 2025, the US Supreme Court declined to block Tennessee's law in US v Skrmetti, allowing the youth gender-affirming care ban to take effect. Lawmakers have also proposed measures to criminally prosecute physicians who provide gender-affirming care and bring civil charges. These efforts challenge clinical ethics, public health goals, and the foundational principles of Medicaid.