The Arbiters of Life and Death
When Politicians Masquerade as Healthcare Professionals
Yes I’ve been absent for a while, and yes I will post an update soon with an explanation. Thank you all for who is still subscribed to this newsletter and is supporting me, it really means the world to me.
This topic has been sitting in my brain for a little bit and with today’s Skrmetti ruling by the Supreme Court this it has become even more important. Please mourn today’s ruling with but also, please don’t forget what those sneaky fuckers tried to slip past us on May 22nd.
With that being said, academic mode on:
Introduction
The passage of the "One Big Beautiful Bill Act" (H.R. 1) by the U.S. House of Representatives on May 22, 2025, represents a significant shift in federal policy toward transgender healthcare access. This budget reconciliation bill, passed by a narrow 215-214 margin, contains provisions that would prohibit federal Medicaid and CHIP funding for gender-affirming care for transgender individuals of all ages.1 The legislation's evolution from a targeted restriction on minors to a comprehensive ban affecting all transgender Americans demonstrates the strategic use of budget reconciliation to advance social policy objectives.
Legislative Development and Last-Minute Expansion
The bill underwent a sly transformation during the final stages of House consideration. Originally drafted to prohibit federal funding for gender-affirming care only for individuals under 18, the legislation was amended during Rules Committee consideration on the evening of May 21, 2025.2 The removal of the word "minors" from the prohibition expanded the scope to encompass all transgender Americans, potentially affecting an estimated 276,000 transgender adults currently enrolled in Medicaid programs.3
This modification occurred during an intensive 26-hour markup process in the House Energy and Commerce Committee, where Republicans advanced the provision on a strict party-line vote of 30-24 after rejecting approximately 100 Democratic amendments.4 The expansion means that about 21% of transgender adults who rely on Medicaid as their primary insurance source could lose access to medically necessary care.5
Specific Legislative Provisions
The legislation contains two primary sections targeting transgender healthcare access:
Section 44125 establishes a prohibition on federal Medicaid and CHIP funding for "gender transition procedures," including puberty blockers, hormone therapy, and surgical interventions. This provision would require states to exclude these treatments from their Medicaid programs or risk losing federal matching funds.6
Section 44201(h) removes gender-affirming care from the definition of "essential health benefits" under the Affordable Care Act. This provision creates a pathway for insurance companies in marketplace plans to exclude transgender healthcare coverage entirely.7
The Congressional Budget Office estimates that the overall legislation would result in $863.4 billion in Medicaid and CHIP cuts over a ten-year period, with 10.9 million individuals losing health coverage across all demographics.8
Congressional Support and Opposition
Representative Dan Crenshaw (R-Texas), the primary architect of the transgender healthcare provisions, has characterized the restrictions as medically necessary. During committee markup, Crenshaw stated: "Gender transition procedures are the lobotomy of our generation. So-called 'gender-affirming care' isn't healthcare—it's fringe science with no proven benefit and massive risks."9
This characterization contrasts sharply with established medical consensus from major professional organizations, including the American Medical Association and American Academy of Pediatrics, which recognize gender-affirming care as medically necessary treatment for gender dysphoria.10
Democratic opposition has been unified, with Representative Mark Takano (California), Chair of the Congressional Equality Caucus, describing the legislation as a "cruel reconciliation bill" that "restricts transgender peoples' access to medically-necessary and lifesaving healthcare—not to save costs, but to distract their base."11
Senate Prospects and Republican Divisions
The legislation faces a more challenging path in the Senate, where Republicans hold a narrow 53-47 majority. Several Republican senators have expressed concerns about various aspects of the bill, though none have specifically opposed the transgender healthcare provisions.12
Senator Josh Hawley (Missouri) has emerged as the most vocal critic of the bill's Medicaid cuts, writing in a New York Times op-ed: "Don't Cut Medicaid" and stating publicly: "Just had a great talk with President Trump about the Big, Beautiful Bill. He said again, NO MEDICAID BENEFIT CUTS."13
Senator Susan Collins (Maine) expressed reservations about the overall approach: "The House bill tries to thread the needle. I'm not certain that they succeeded, but I'm still looking at the specifics."14 Senator Lisa Murkowski (Alaska) has raised concerns about the impact on tribal communities heavily reliant on Medicaid programs.15
Historical Context and Precedent
This federal legislation represents an escalation from previous anti-transgender policy initiatives. The National Defense Authorization Act for Fiscal Year 2025 already banned TRICARE coverage for gender-affirming care for children of military families under 18, affecting approximately 6,000-7,000 children.16
Currently, ten states have enacted bans on Medicaid coverage for transgender care for all ages, but federal intervention would create uniform restrictions nationwide regardless of state policy preferences.17 The American Civil Liberties Union has documented 575 anti-LGBTQ+ bills at the state level in 2025, indicating a broader pattern of legislative action targeting transgender rights.18
Policy Implications and Future Considerations
The use of budget reconciliation to advance social policy represents a significant procedural development. While reconciliation has traditionally been used for fiscal matters, the inclusion of these healthcare restrictions demonstrates how budgetary procedures can be leveraged to implement sweeping policy changes without the need for separate legislative votes.19
The legislation's potential impact extends beyond the transgender community. The Human Rights Campaign has noted that the bill's cuts to programs like Medicaid and SNAP, combined with restrictions on healthcare access, represent a comprehensive approach to limiting federal social support programs.20
Conclusion
The "One Big Beautiful Bill Act" represents a watershed moment in federal transgender policy, transforming from a targeted restriction into the most comprehensive federal limitation on transgender healthcare access in American legislative history. The strategic expansion of the bill's scope demonstrates how must-pass legislation can be used to advance controversial social policies. With narrow Republican majorities in both chambers and an administration supportive of these restrictions, the legislation faces strong prospects for enactment, potentially establishing precedent for future use of budget reconciliation to implement significant social policy changes.
Reuters, "US House narrowly passes Trump's sweeping tax-cut bill, sends on to Senate," May 22, 2025.
The Intercept, "Republicans Launch Midnight Attack on Health Care Access for Trans Americans," May 22, 2025.
Georgetown University Center for Children and Families, "Medicaid and CHIP Cuts in the House-Passed Reconciliation Bill Explained," May 27, 2025.
Fierce Healthcare, "House Budget Committee overcomes conservative pushback to advance reconciliation package," 2025.
WNCT, "Trump agenda bill would block Medicaid from covering gender-affirming care," 2025.
Brown Hutchinson Farrington Shewmaker (BHFS), "Summary of Health Care Provisions in the 'One Big Beautiful Bill Act,'" 2025.
Ibid.
Georgetown University Center for Children and Families, "Medicaid and CHIP Cuts in the House-Passed Reconciliation Bill Explained," May 27, 2025.
Representative Dan Crenshaw, "Congressman Crenshaw's Amendment Protecting Minors from Gender Transition Procedures Advances," Press Release, May 2025.
American Medical Association, "AMA Position on Gender-Affirming Care," 2024.
Congressional Equality Caucus, "CEC Blasts GOP Bill to Cut Medicaid & Target Trans Americans' Healthcare," Press Release, 2025.
Yahoo! News, "6 Senate Republicans who could hold up Trump's 'big, beautiful bill,'" 2025.
Ibid.
Ibid.
Ibid.
The Hill, "Senate passes $895 billion defense bill, including transgender care provision," 2024.
Trans Legislation Tracker, "2025 Anti-Trans Bills," 2025.
Ibid
The Washington Post, "Senate returns with Trump's massive tax and immigration bill on the agenda," June 2, 2025.
Human Rights Campaign, statement on H.R. 1, May 2025.