The Federal Move

On December 18, 2025, Health Secretary Robert F. Kennedy Jr. and Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz announced two proposed rules at HHS headquarters that would create an effective nationwide prohibition on gender-affirming medical care for minors—a step beyond the 27 state bans already in place.

What the Rules Actually Say

According to NPR, the first rule prohibits doctors and hospitals from receiving Medicaid reimbursement for gender-affirming care provided to any patient under 18. Medicaid serves low-income Americans, already the most vulnerable group in healthcare policy disputes.

The second rule extends the restriction further. It blocks ALL Medicare and Medicaid funding from any hospital that provides pediatric gender-affirming care — regardless of the service provided. Virtually every hospital in the United States accepts Medicare, making this funding leverage substantial.

"So-called gender affirming care has inflicted lasting physical and psychological damage on vulnerable young people," Kennedy said at the announcement. "This is not medicine. It is malpractice."

The announcement will face immediate legal challenges.

The Scale of Who's Affected

The Williams Institute at UCLA Law quantifies the reach. According to their January 2025 analysis, 300,100 youth ages 13-17 identify as transgender in the United States. Of those, roughly 180,000 live in states that currently allow access to gender-affirming care.

Those 180,000 young people in states where legislatures decided this care should remain legal are directly affected by the federal funding rules. Even private insurance patients get caught in the scope because the rules threaten the entire hospital's federal funding stream, not just reimbursement for specific procedures.

Where the States Already Stand

According to KFF's policy tracker, updated May 19, 2026, 27 states have already enacted laws or policies limiting youth access to gender-affirming care. Fifty percent of transgender youth ages 13-17 now live in a state with such restrictions.

The Supreme Court handed the state-level movement a significant decision on June 18, 2025, ruling in United States v. Skrmetti that Tennessee's ban on gender-affirming care did NOT constitute sex-based discrimination and did NOT violate the 14th Amendment's Equal Protection clause. Twenty-five bans remain in place following this decision.

Two states have different legal status. Montana's ban is permanently enjoined based on the state constitution. Arkansas's ban is also blocked—a federal court found it violated both Equal Protection AND Due Process clauses, with the Due Process portion surviving the Supreme Court ruling.

Twenty-four states impose professional or legal penalties on healthcare practitioners who provide minors with this care, according to KFF. Eighteen states continue to fight active lawsuits.

What the Pushback Looks Like

The American Academy of Pediatrics responded directly. AAP President Dr. Susan J. Kressly said the administration's rules "misconstrue the current medical consensus and fail to reflect the realities of pediatric care and the needs of children and families."

The Williams Institute report notes that a consensus of major U.S. medical associations supports gender-affirming care for transgender youth and that care protocols have been "reviewed and refined over the course of over 40 years."

Legal and Constitutional Questions

Executive actions require statutory authority. These proposed rules will face immediate legal challenges. Proposed rules are not final rules, and the litigation process could take years.

On the constitutional question, the Supreme Court's 6-3 decision in Skrmetti on the Equal Protection issue represents a significant legal development. On the federal authority question, courts have yet to rule on whether HHS can leverage Medicare and Medicaid funding to regulate care in this manner.

Practical Effects

If these rules survive legal challenge, a hospital in California or Illinois—states that explicitly kept this care legal—faces a choice: stop providing gender-affirming care to minors or lose Medicare funding for its entire operation. Every senior patient. Every disabled patient. All other services.

This mechanism would create pressure even in states where legislatures decided to allow the care.

The 300,000 transgender youth, their families, hospitals, and courts will now determine which rules are enforceable and which are not.