UPDATE: In a narrow 215–214 vote early Thursday morning, the U.S. House of Representatives passed President Donald Trump’s sweeping “One Big Beautiful Bill Act.” A significant amendment to the bill now extends the prohibition of federally funded gender-affirming care to include adults, not just minors. This change broadens the scope of the ban, affecting transgender individuals of all ages who rely on Medicaid or Affordable Care Act (ACA) marketplace plans for healthcare coverage.
The amendment, introduced late Wednesday, removed language that previously limited the ban to minors, thereby expanding its reach. Under the revised bill, Medicaid and ACA plans would be prohibited from covering gender-affirming procedures, including hormone therapy and surgeries, for transgender adults. This move has drawn sharp criticism from LGBTQ+ advocates and healthcare professionals, who argue that it undermines the rights and well-being of transgender individuals.
House Speaker Mike Johnson (R-La.) heralded the bill’s passage as a significant victory, stating, “What we’re achieving today is nothing short of historic.” The bill now advances to the Senate, where it faces further debate and potential revisions.
A new federal proposal titled the One Big Beautiful Bill Act may sound like a harmless budget package. But for transgender Americans, it is anything but. If passed, it would strip away insurance protections, eliminate Medicaid coverage, and redefine gender in law in ways that would profoundly limit or erase access to transition-related care. Experts warn that it’s not just a health policy shift; it’s a key step in the Trump administration’s Project 2025 agenda to dismantle LGBTQ+ rights through federal power.
Here’s what’s in the bill, who it affects, and what could happen next.
The Bill’s Direct Impact on Transgender Health Care
The One Big Beautiful Bill Act contains language that would ban nearly all federally supported gender-affirming care for minors and remove it from the list of services insurers are required to cover under the Affordable Care Act.
Medicaid and CHIP Funding Cut for Trans Youth
Section 44125 of the bill explicitly states that federal Medicaid and Children’s Health Insurance Program (CHIP) funds may not be used for “specified gender transition procedures” for individuals under 18. This prohibition applies regardless of the medical necessity or the recommendations of doctors, psychologists, or even parents. It effectively creates a blanket ban on care that major medical institutions, including the American Academy of Pediatrics and the American Medical Association, have deemed medically necessary and evidence-based.
The bill defines these procedures in Section 1905(kk) to include a sweeping array of interventions, such as:
- Surgeries: including mastectomy, phalloplasty, vaginoplasty, facial feminization or masculinization, and genital reconstruction surgeries.
- Hormone-based treatments: such as puberty blockers, testosterone, and estrogen when administered for gender-affirming purposes.
- Cosmetic procedures used in gender transition: including hair removal, vocal training, or facial implants.
Even when medically indicated to alleviate severe gender dysphoria or prevent suicidal ideation, these interventions would be disqualified for public funding. The only exceptions are for individuals with verified intersex conditions or when the treatment is needed to correct an injury or illness not related to gender identity.
This provision would especially devastate low-income families, many of whom rely on Medicaid as their only access point to healthcare. With no other coverage option, trans youth in these households would be forcibly cut off from transition-related care that may already be in progress.
ACA Plans Would Drop Gender-Affirming Coverage
Another critical blow comes in the form of Section 1302(b)(2)(C), which would amend the Affordable Care Act to specifically exclude gender transition procedures from the definition of “essential health benefits.” Starting in 2027, health plans on the ACA marketplace would no longer be required, or even allowed, to cover gender-affirming care.
This could include denial of coverage for:
- Hormone therapy (even for adults)
- Counseling and therapy services related to gender identity
- Any surgery intended to align someone’s physical traits with their gender identity
While some private insurers might continue coverage voluntarily, the majority are expected to follow federal guidelines, especially in conservative states. This would lead to a healthcare landscape where trans people could face wildly inconsistent access based solely on where they live or which insurer they use.
The bill makes clear that “no funds made available through a qualified health plan shall be used to provide coverage for a gender transition procedure,” regardless of age, need, or outcome.
A Legal Definition of Sex That Ignores Gender Identity
Perhaps most insidious is the bill’s redefinition of “sex” under federal healthcare law. Section 1905(kk)(3) establishes a purely biological framework for sex:
“The term ‘sex’ means either male or female, as biologically determined… The term ‘female’ means an individual who… produces, transports, and utilizes eggs for fertilization… The term ‘male’ means an individual who… produces, transports, and utilizes sperm for fertilization.”
This narrow, anatomy-based definition intentionally erases transgender and nonbinary people from federal legal recognition. It further paves the way for eliminating gender identity from anti-discrimination protections, healthcare access, housing rights, and beyond.
By enshrining sex in terms of gamete production, the bill sets up a hostile standard not only for trans people but also for intersex individuals and anyone whose biology does not fit rigid binaries. It also directly contradicts modern medical understanding of sex and gender as spectrums rather than absolutes.
Tax Increases That Will Disproportionately Impact Trans People
While much of the public discourse around the One Big Beautiful Bill Act has focused on its impact on healthcare access, the bill also contains sweeping tax reforms that could further burden transgender individuals, particularly those already facing economic hardship.
For example, the bill eliminates several itemized deductions and imposes stricter limitations on others. One provision terminates the deduction for out-of-pocket medical expenses related to gender transition care, meaning that trans individuals who pay for hormones, surgeries, or therapy out of pocket would no longer be able to write those costs off. This change could increase annual tax bills by hundreds or even thousands of dollars for individuals managing their own care without insurance support.
Additionally, the bill eliminates the tax credit for employer-provided educational assistance and makes changes to the earned income tax credit (EITC) that would reduce the refund amounts for low-income workers. Trans people, who are more likely than the general population to face employment discrimination or work part-time jobs without benefits, stand to lose crucial tax relief that has helped many survive.
These financial penalties, combined with the loss of subsidized care, amount to a coordinated fiscal squeeze on an already marginalized community. Rather than supporting health and economic stability, the bill creates new barriers at every level of daily life.
Could This Become Law?
The bill has already cleared its first major hurdle: it passed the House Budget Committee and is expected to pass the full House, which is currently controlled by Republicans. However, its fate in the Senate remains uncertain.
Currently, the Senate is split 53-45-2 in favor of Republicans. However, because the budget reconciliation process is packaging this bill, a 60-vote filibuster threshold may not apply. This process allows for certain budget-related legislation to pass with a simple majority.
If reconciliation rules apply, all it would take is 50 Senate votes and the signature of Vice President J.D. Vance to send this bill to President Trump’s desk.
Another critical factor that could influence the bill’s trajectory is the Supreme Court’s pending decision in United States v. Skirmetti. That case challenges a Tennessee law banning gender-affirming care for minors and is expected to rule on whether such bans violate constitutional protections under the Equal Protection Clause or parental rights.
If the Court strikes down the Tennessee law, it could make parts of the One Big Beautiful Bill Act unenforceable. But if the Court upholds the law, it could open the door for federal and state bans to proliferate unchecked. Legal experts warn that the Court’s ruling could serve as either a safeguard or a green light, and the stakes are high.
A Glimpse Into Project 2025
The One Big Beautiful Bill Act is not an isolated effort. It mirrors nearly every major policy recommendation outlined in Project 2025, a sweeping governance blueprint released by the Heritage Foundation and endorsed by many Trump-aligned think tanks and former administration officials.
Project 2025 calls for:
- Redefining “sex” in federal law to exclude gender identity
- Eliminating all federal funding for gender-affirming care
- Rolling back non-discrimination protections for LGBTQ+ people
- Restructuring or dismantling federal agencies that support LGBTQ+ programs
This bill is a textbook implementation of those goals. It seeks to restructure federal health policy through narrow definitions, funding restrictions, and bureaucratic erasure. By removing gender identity from law and policy, it pushes transgender people out of visibility and access, one regulation at a time.
It also sends a chilling message: that medical consensus, lived experience, and human dignity can be overruled by ideology. The Trump administration isn’t just promoting anti-trans policies. It is institutionalizing them.
What Trans People and Allies Can Do
First and foremost, stay informed. Read the bill’s text. Understand how it might affect you or someone you love. Knowledge is power, and this bill depends on people being too exhausted or overwhelmed to resist.
Next, contact your senators. Especially if you live in a swing state, your voice matters. Demand that they oppose this bill and any attempt to fast-track it through reconciliation.
Support national and grassroots organizations that are pushing back legally and politically. Groups like the ACLU, Transgender Law Center, and trans-led advocacy networks are fighting in the courts and in the streets.
Finally, protect your mental health. The emotional toll of being targeted by national policy can be intense. Connect with the community. Talk to friends. Take breaks from the news. You do not have to carry this alone.
Final Thoughts
This bill is not about fiscal policy. It is about erasure. It is about codifying a worldview where trans lives are invisible, invalid, and expendable. But trans people are real. We exist. We love. We fight. And we have always endured.
To every transgender person reading this: you are not a burden. You are not a debate. You are not alone. The One Big Beautiful Bill Act may try to erase you. But your truth, your care, and your future are worth defending. And we will defend them. Together.
