The U.S. House of Representatives passed its version of the tax and spending bill supported by President Trump early on Thursday morning. A last-minute change to the bill, apparently to make it more appealing to rightwing members of Congress threatening to vote no, targets transgender Americans. An amendment to the bill’s ban on Medicaid paying for transition-related care for anyone under 18 removed the words “for minors” from one line and “under 18 years of age” from another, expanding the ban on Medicaid paying for such procedures to cover everyone, adult and minor.
Another anti-trans provision of the bill, which President Trump has been promoting as his “one big beautiful bill,” eliminates “gender transition procedures” as “essential health benefits” guaranteed by the Affordable Care Act (ACA, also known as Obamacare). That means health insurance policies offered by the ACA Marketplace would no longer have to cover the procedures.
According to the Williams Center of the UCLA School of Law, “approximately 276,000 transgender adults are enrolled in Medicaid nationally.” Reliable data on the number of trans people under the age of 18 covered by Medicaid and the number of trans people covered by insurance provided through the ACA Marketplace isn’t available.
The Medicaid ban “marks a significant and unprecedented escalation — effectively the first major federal effort to restrict access to transition-related care for adults,” journalist Erin Reed wrote. “It also confirms what many transgender advocates have long warned, and what some GOP operatives have candidly admitted: the endgame isn’t protecting children — it’s banning care for everyone.”
That’s already happened in Iowa. In 2023, Gov. Kim Reynolds signed into law a ban on gender-affirming care for trans Iowans under the age of 18, regardless of whether parents support that care or doctors consider it medically necessary. This year, Republican leaders in the legislature inserted a provision into the budget bill for the Iowa Department of Health and Human Services (HHS) and the Iowa Department of Veterans Affairs that prohibits Medicaid from paying for any gender-affirming care for trans Iowans. The only exception is mental health counseling.
In 2019, Iowa Republican attempted to ban Medicaid from paying for gender-affirming care for trans people by introducing a last-minute change in a budget bill. The ban was struck down by a Polk Country District Court, which found it would “violate the Iowa Civil Rights Act and the Equal Protection Clause of the Iowa Constitution.” The first bill Gov. Reynolds signed into law this year removed gender identity from the Iowa Civil Rights Act, eliminating protections for trans, nonbinary and gender nonconforming Iowans. That bill also altered state law to erase any official recognition by state and local governments of trans people as trans people.
As the LGBTQ civil rights organization GLAAD explains on its site, “Every major medical association and leading world health authority supports health care for transgender people and youth.” GLAAD links to statements issued by more than 30 major medical associations, including the American Medical Association and the American Psychiatric Association.
According to Erin Reed, the last-minute amendment to the House budget bill was “reportedly introduced to win back support from hardline conservatives after concessions were made to the party’s more moderate wing.” Various hardliners had been very vocal about wanting even steeper cuts to Medicaid than the bill originally offered, and cuts to the program were increased. But so far, no one has taken credit for banning funding for medical care for trans Americans.
The overall cuts to Medicaid in the bill are the largest proposed cuts in history. The nonpartisan Congressional Budget Office (CBO) estimates the House bill will end Medicaid coverage for 8.7 million people and led to an additional 7.6 million Americans to go without health insurance over the next 10 years.
Congressional Republicans and President Trump insist the cuts to Medicaid aren’t actually cuts to Medicaid, just money-saving reforms that will eliminate waste, fraud and abuse, and make sure only people who deserve help covering medical expenses get it.
The Kaiser Family Foundation (KFF), a leading research center on healthcare issues, estimates Iowa will lose $518 million in federal funds for Medicaid if the House bill is signed into law, and over 86,000 Iowans would lose their Medicaid coverage.
According to KFF, approximately 603,000 adults and children in Iowa are currently covered by Medicaid. The program covers 38 percent of births in the state, and it provides medical coverage for 38 percent of Iowa children. Half of all nursing home patients rely on Medicaid.
Despite massive cuts to almost all domestic programs, the CBO estimates the budget bill will add $2.4 trillion to the national debt over the next 10 years. That increase is driven by billions in additional spending on the military and on immigration enforcement, and especially by the extension of tax cuts passed during President Trump’s first administration. Those tax cuts overwhelmingly favor the wealthiest Americans.
Whether the House could pass the bill remained uncertain almost up until 7 a.m. on Thursday morning, when the final votes were counted. All the chamber’s Democrats voted against it, and because Republicans have such a narrow majority, just three GOP no votes would have stopped the bill. House leadership continued to change the bill until the last minute, mostly to appease far-right members of the caucus. In the end, it passed by one vote.
All four members of Iowa’s House delegation voted in favor of the bill. That was expected. None of them have shown any willingness to defy their party’s leadership, regardless of the content of a bill. And of course, none of them have ever defied President Trump.
The bill now goes to the Senate. It is expected the Senate will make some changes to it. It is not expected that Republican senators will change the anti-trans Medicaid ban.
