California's protections for transgender care could be tested under Trump

LOS ANGELES — When Mars Wright saw that Donald Trump had been elected again as president, the 29-year-old Los Angeles artist and streetwear designer felt relieved he had already undergone surgeries for his gender transition.

Wright, a transgender man, has chronicled his medical journey online, flexing and dancing to show how his body transformed after a masculinization procedure he nicknamed "Dorito chip" for the way it altered his shape. His surgery was covered under an L.A. Care plan he obtained through Covered California, the marketplace set up under the Affordable Care Act for Californians to purchase insurance.

"I'm privileged to be here," Wright said of living in California. "And I think about how people are going to have to come here ... to be able to have medical transition."

California leaders have sought to protect access to such procedures for transgender people. Health plans licensed by the state must provide transgender enrollees with medically necessary gender-affirming care. Doctors who provide such care in California are legally shielded from laws criminalizing it in other states.

But experts and advocates said that even in California, access to gender-affirming care could be undermined by federal action as Trump takes office for a second time, pledging to stop "left-wing gender insanity" and calling gender transition for minors a form of child abuse. State lawmakers have pledged to push back against efforts to obstruct gender-affirming care, which could tee up future battles in court.

"I'm not going to sit here and say that California can turn back every despicable federal attack on trans people," said state Sen. Scott Wiener (D-San Francisco), who has backed protections for transgender patients and their doctors. "But we are going to do everything in our power to stick up for the community."

President-elect Trump has vowed to press Congress to block the use of federal funds for gender-affirming care including surgery, a position also reflected in the Republican party platform. Exactly how a ban would be imposed remains to be seen, but experts said the Trump administration could model it on the Hyde Amendment, which for decades has broadly banned using federal funds for abortion.

Eliminating federal funding would have sweeping effects, because "pretty much every corner of the health care system has some element of federal funding in it," said Kellan E. Baker, executive director of the Whitman-Walker Institute, which does research and advocacy on health issues for LGBTQ people. Its effects "would fall most significantly on those who are least positioned to be able to afford the health care they need."

Among those affected, he said, would be transgender people who rely on public programs such as Medicaid. However, experts said that because Medicaid is jointly funded by states and the federal government, California leaders could choose to use state funds to pay for gender-affirming care.

"California has shown a predilection for funding things that are over and above what Medicaid nationally will do," such as covering low-income Californians regardless of immigration status, said John Baackes, chief executive of L.A. Care, a health plan serving more than 2 million people across L.A. County. "The state could say, 'OK — we'll fund it.'"

Trump is also expected to seek changes to Medicaid that would reduce federal spending, which could strain for California financially if it wants to continue other existing programs under Medi-Cal, the state's Medicaid program. But advocates said because transgender people are a small share of the population — estimated at 0.6% of U.S. teens and adults in one analysis — shouldering costs for gender-affirming care wouldn't be a major expense.

Experts said states have wide latitude over their spending, but Trump has tried to use Medicaid to pressure California over its policies before. Near the end of his first term, the Trump administration threatened to withhold some Medicaid funding from California because the state required insurers to cover abortion care.

That threat ultimately fizzled, but it could hint at how his administration might try to pressure California. A Trump representative didn't respond to an email seeking comment on that possibility.

At clinics run by the Los Angeles LGBT Center, anxious patients are asking, "Should I get a year's worth of hormones now? Should I do all the surgeries I've ever wanted to do?" said Dr. Kaiyti Duffy, its chief medical officer. She has tried to assure them that "as long as we can provide these services, we will."

Trump could also pursue more sweeping restrictions that not only bar the use of federal dollars for gender-affirming care, but prohibit providers of such care from getting federal funding.

Some of his proposals specifically target gender-affirming care for youth, which has been a focal point for groups that contend it harms children who don't understand the implications of such treatment. Greg Burt, vice president of the California Family Council, called it "the biggest lie that this state has ever perpetrated on our young people, to tell kids that it's possible to be born in the wrong body."

The American Academy of Pediatrics recommends that transgender youth have access to comprehensive gender-affirming care.

In the Central Valley, one mother said puberty blockers had been a "pause button" that relieved despair for her transgender child, who is now 14, and gave the family time to figure out what he needed. The military family, who rely on Tricare insurance for service members that is federally funded, consulted with doctors and eventually moved forward with hormonal treatment with testosterone.

"At every stage of medical care, he became more and more himself," said the mother, who asked not to be identified to protect the privacy of her teen. "He switched from being silent and quiet to active and alive and thriving."

If her child is blocked from getting such care in California, she said, they are making plans to leave the country.

Trump has called to prohibit gender-affirming care for youth in every state, calling it mutilation. During the campaign, Trump said he would seek to terminate any health care provider that "participates in the chemical or physical mutilation of minor youth" from Medicaid and Medicare.

The Medicare and Medicaid programs are "the biggest lever that the federal government has because hospitals get so much money" from them, said Julianna S. Gonen, director of federal policy for the National Center for Lesbian Rights. The threat of losing it "is so severe that hospitals will probably comply before they run the risk of being terminated from the programs."

Experts said the White House could also seek a federal determination that such care is dangerous or experimental, which would reverberate through federally funded programs.

Alejandra Caraballo, a clinical instructor at the Cyberlaw Clinic at Harvard Law, said for many health care providers, "when the risk is you losing your federal funding — which means your ability to operate — it's easier to just drop a trans patient."

The Trump administration could also roll back federal regulations that bar health care providers from denying care to transgender patients if the same kind of care is provided to others. However, California has its own rules prohibiting health plans from denying care based on gender identity.

The Trump administration could also try to clamp down on hormonal therapy through Food and Drug Administration regulations, some believe. However, Amanda McAllister-Wallner, interim executive director of the consumer advocacy group Health Access California, said trying to pinpoint who is providing "gender-affirming care" could be thorny for federal officials because such interventions are also used for other conditions.

"It's not necessarily obvious — was this service being provided because of someone's diagnosis of gender dysphoria or for some other reason?" McAllister-Wallner said.

One study of insured patients published in JAMA Network Open found that in a recent year, breast reductions for trans youth were far outnumbered by ones for boys who are not transgender. Researchers said surgeries for transgender teenagers were "rare and almost entirely chest-related procedures" and found no surgeries on trans youth ages 12 or under.

Before election day, Bamby Salcedo planned to push for improvements to gender-affirming care through a Medi-Cal initiative called CalAIM. The election shunted that effort to the back burner, said Salcedo, president and chief executive of the TransLatin@ Coalition, an advocacy group founded by transgender women in L.A.

In its aftermath, Salcedo was continuing to push for an L.A. County budget allocation to support the needs of trans people, saying local government needs to step up. And she was also busy planning for a fashion show celebrating 15 years of her organization, calling it a chance "for that one night to bring joy to our people."

"In whatever way possible, we are going to get through this," she said.

Wright was among the designers being showcased at the event. Before getting his surgical procedures, he said, "I was scared to date. I was scared to wear clothes that I liked. I was scared to go to the beach." Now, he joked, "I can't keep my shirt on."

"I'm at a place where I love being trans."