Portrait of a young transgender woman in a library. Credit: FG Trade / iStock
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January 2, 2026
What happens when federal power overrides medical judgment? This blog examines new efforts to defund gender-affirming care for youth and the far-reaching implications for healthcare access and governance.
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In December 2025, the Trump administration escalated its efforts to restrict gender-affirming care (GAC) for transgender youth through a sweeping set of federal actions that go far beyond existing state bans. Under proposals released by the Department of Health and Human Services, children and adolescents under 18 would be barred from accessing gender-affirming medical care nationwide—not through an act of Congress, but by threatening the financial survival of hospitals and health systems that provide it.
Already, more than half of U.S. states ban or severely limit gender-affirming care for minors, according to the Kaiser Family Foundation. The new federal proposals would extend those restrictions even into states that protect access, effectively creating a national ban through funding leverage rather than lawmaking.
The administration announced three interlocking actions on Dec. 18 that together would dramatically curtail care for transgender youth.
First, the Centers for Medicare & Medicaid Services (CMS) proposed a new Condition of Participation rule that would require hospitals to stop providing gender-affirming care to anyone under 18 as a prerequisite for receiving any Medicare or Medicaid funding. This requirement would apply regardless of whether a patient uses private insurance or pays out of pocket. For most hospitals, participation in these federal programs is not optional—making compliance all but unavoidable.
Second, CMS proposed a separate rule that would ban federal Medicaid and the Children’s Health Insurance Program funding for gender-affirming care for youth. Medicaid coverage would be prohibited for patients under 18, while CHIP coverage would be barred for those under 19. Even if a doctor determines that care is medically necessary for an individual patient, federal funds could not be used.
Third, HHS Secretary Robert F. Kennedy Jr. issued an unprecedented declaration, asserting that gender-affirming care for youth is “neither safe nor effective.” Legal experts warn that this declaration could be used to justify excluding providers from federal health programs altogether—without the usual public notice-and-comment process required for major policy changes.
CMS has never before conditioned Medicare or Medicaid participation on the elimination of a specific medical service, particularly one supported by major medical organizations. If upheld, this approach could set a powerful precedent: allowing the federal government to dictate which medical services hospitals may offer, even when those services are legal under state law and supported by clinical evidence. Health policy experts warn that the same mechanism could later be used to target other politically controversial forms of care, from reproductive health services to mental health treatments.
While public debate often centers on surgeries or hormones, the majority of gender-affirming care for youth consists of counseling and mental health services.
The Medicaid proposal is similarly consequential. Historically, states—not the federal government—determine what is medically necessary under Medicaid, particularly for children through the program’s Early and Periodic Screening, Diagnostic, and Treatment benefit. The proposed rule would override those individualized determinations, shifting decision-making power decisively to federal officials.
While public debate often centers on surgeries or hormones, the majority of gender-affirming care for youth consists of counseling and mental health services. Medical interventions such as puberty blockers or hormones are prescribed to a very small fraction of adolescents—estimated at fewer than 0.1 percent nationwide.
Still, the practical impact of the proposals would be sweeping. Hospitals would be forced to stop providing gender-affirming care to minors entirely, even in states that allow it. Lower-income families relying on Medicaid or CHIP would face the steepest barriers, but even privately insured families could lose access as providers exit care altogether to protect their funding.
Major medical organizations, including the American Academy of Pediatrics and the American Medical Association, have strongly objected to the administration’s claims that gender-affirming care is unsafe or ineffective. They argue the HHS declaration misrepresents the medical consensus and substitutes political judgment for clinical expertise.
More than access to gender-affirming care is at stake. If these rules survive legal scrutiny, they would significantly expand the federal government’s role in setting national standards of medical care—traditionally the domain of states, clinicians and professional organizations.
Legal challenges are already underway. Courts have previously issued nationwide injunctions preventing the administration from cutting off federal funds solely because providers offer gender-affirming care. The new proposals are expected to face immediate lawsuits alleging violations of administrative law, statutory limits on federal authority, and constitutional principles governing medical regulation.
More than access to gender-affirming care is at stake. If these rules survive legal scrutiny, they would significantly expand the federal government’s role in setting national standards of medical care—traditionally the domain of states, clinicians and professional organizations.
For transgender youth and their families, the consequences are immediate and personal. For the broader healthcare system, the implications are structural and long-lasting. The question raised by these proposals is not only who gets care, but also who decides what care is allowed at all.
Public comments on the proposed rules are due in February 2026. Until then, the future of gender-affirming care for young people—and the boundaries of federal power in medicine—remain uncertain.
Join Dr. Vin Gupta and AFT President Randi Weingarten for a powerful on-demand webinar with Casey Pick, Senior Director from The Trevor Project, the leading organization providing crisis intervention and suicide prevention services for LGBTQIA+ young people. Together, they explore what it means to be an ally in practice, whether you’re in a classroom, clinic or public service role.
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