More and More Republican States are Quietly Restricting Trans Adults’ Healthcare Access. Nobody’s Noticed.

Republicans’ policies restricting Medicaid coverage of gender-affirming care are slipping by completely unacknowledged. That’s dangerous.

Rep. Dan Crenshaw, Florida Gov. Ron DeSantis, Louisiana Gov. Jeff Landry, and Montana Gov. Greg Gianforte have all moved to restrict trans adults’ healthcare | Images: Wikimedia Commons

Over the past few years, Republicans have employed many different narratives in their push to restrict the rights of transgender Americans. Of these, almost all are entirely manufactured: “fairness in sports,” “safety in bathrooms,” “protecting kids,” “biological truth,” and even “the root of evil” are all baseless talking points that have only recently entered political discourse.

But, in moving to restrict trans adults, Republicans have also relied on another argument: the idea that gender-affirming care is inherently optional and not at all medically necessary.

Unlike the other parts of anti-trans rhetoric, this one isn’t new. For decades, transgender Americans have faced many difficulties in getting health insurance—both public and private—to cover their care, but thanks to a combination of advocacy and legal action, things had been improving substantially up until a few years ago. During this time, many blue states passed legislation enshrining access to care, and lawsuits over Medicaid coverage and care access for those in correctional facilities resulted in many red states’ restrictive policies being struck down.

Although most of this flew under the radar, a reaction eventually came. As part of bans on gender-affirming care for minors, most bills included somewhat redundant prohibitions on public funds going towards care for trans kids. But even then, some still weren’t satisfied: in 2023, Florida and Missouri expanded this provision to restrict trans adults’ Medicaid coverage as well, as did South Carolina when it passed its trans youth care ban the next year.

Following this, Idaho and Kentucky passed entirely new bills with the sole purpose of implementing these broader Medicaid bans, and Iowa—in defiance of a 2023 Iowa Supreme Court ruling—also included the measure in a 2025 appropriations bill.

That same year, a federal Medicaid ban was passed by the House as part of the “Big, Beautiful Bill” before being removed in the Senate. Dan Crenshaw (TX-02), the driving force behind that provision, primarily characterised it as a waste of money, listing the following justification on his website:

“[Gender-affirming care procedures] are not treatments. They are permanent, damaging interventions being forced on vulnerable kids and adults in the name of radical ideology. And the federal government should have no hand in it.”

And the public agrees with him. According to a Pew Research Center poll from last year, 53% of Americans oppose requiring health insurance coverage of gender-affirming care, up from 44% in 2022. Conversely, in that same 2025 poll, only 22% supported the idea, a decrease of 5% from three years prior.

But despite this popularity, Republicans don’t always lean into this issue or make a spectacle. In fact, of the 12 states that have implemented at least some form of restrictions on Medicaid coverage of gender-affirming care in recent years, only 6 have actually said something about it.

And in the other 6? Silence. There were no conservatives bragging about “saving taxpayer dollars,” informational press releases, or, with the exception of Louisiana, even people who noticed at all. That’s a massive problem.

The most recent state to cut gender-affirming care coverage was Kansas. Back in October of last year, the Kansas Department of Health and Environment released a series of bulletins announcing that gender-affirming care would no longer be covered by Kansas’ Medicaid program. Under the new policy, which was applied retroactively and with no notice, only those who were over the age of 21 on September 1st, 2025, and had already “undergone surgical and/or medical (hormonal) gender affirmative treatment” will keep their coverage. The minimum age of 21 is a result of the fact that Kansas now considers gender-affirming care for those under 21 to be “experimental.”

A few months earlier, Louisiana, despite being one of the few Republican-controlled states to have an entire policy dedicated to its coverage of gender-affirming care, also implemented a ban without formally rescinding the policy. Overnight, the state’s Department of Health stopped reimbursing providers for gender-affirming services, including surgery. As mentioned earlier, this is the only quiet change to receive any sort of media attention.

Additionally, in January 2025, with no explanation, public notice, or fanfare, Wyoming updated its Medicaid program to include an explicit exclusion for gender-affirming care. Before this, the state had no explicit policy, something which usually means transgender healthcare is covered when determined to be medically necessary.

Then there’s fee schedules, which are documents that assist medical providers with billing and outline covered treatments. For states that don’t make mention of gender-affirming care in their policies, fee schedules can provide an important window into coverage of gender-affirming surgery—which has the treatment codes of ‘55970’ for trans women and ‘55980’ for trans men. It’s with these next three states that this story gets a little upsetting.

First is South Dakota. Strangely, until the state passed a sports ban in 2022, transgender people weren’t acknowledged by the state’s laws in any way. Even today, South Dakota is the only state in American history to have never implemented any sort of law or policy concerning trans people’s birth certificates or IDs.

As part of this, for many years, South Dakota was thought to have no explicit policy concerning gender-affirming care. However, when the state’s Department of Social Services updated its website in early 2024 and added a comprehensive fee schedule, it was finally revealed that the state doesn’t cover gender-affirming surgery.

And it isn’t just South Dakota. For the past 8 years, it has been understood that Montana’s Medicaid plan covered gender-affirming care. This idea stems from a 2017 document announcing coverage of “services related to gender transition” that was released by the Montana Department of Public Health and Human Services—which was under the leadership of Democratic Governor Steve Bullock at the time.

Following this, despite the fact that the document was scrubbed from government websites sometime in 2020, Montana had made no further statements on the matter—but that didn’t necessarily mean the previous policy remained in place. When Republican Greg Gianforte took office in 2021, Montana’s fee schedules were updated to once again exclude gender-affirming surgery. Because the state did this secretly, this went unacknowledged for 4.5 years.

Finally there’s Mississippi, another state that supposedly has no policies on trans healthcare. Once again, this is only partially true. According to fee schedules spanning over a decade, Mississippi has maintained an exclusion of gender-affirming surgery since September 2012. This means that for 13 and a half years, Mississippi has gotten away with everyone being unaware that they are denying trans people healthcare. For 13 and a half years, Mississippi got away with all the hate and faced none of the consequences.

That said, in a bit of positive news, fee schedules have also revealed that Indiana—which is widely believed to have no explicit policy—has actually covered gender-affirming care for the past 10 years. With that, this is what a map of Medicaid policies in the United States currently looks like:

For sources, tables, and more maps, head to Transitics’ CATPALM page.

It’s important to note that for the ~20% of trans people who rely on Medicaid, that is likely their only option to receive the care they need to live. And right now, an increasing number of Republican states aren’t just taking that right away; they’re taking it without people finding out. It’s impossible to overstate just how dangerous that is.

And worst of all, anti-trans conservatives aren’t doing this quietly to score political points—they’re doing it to be cruel. If unimpeded, that cruelty will only continue to grow. Simply put, they cannot be allowed to get away with stripping our rights unnoticed. Trans people’s livelihoods depend on it.