When Mars Wright saw that Donald Trump had been re-elected president, the 29-year-old Los Angeles artist and streetwear designer felt relieved that he had already undergone gender transition surgery.
Wright, a transgender man, has chronicled his medical journey online, flexing and dancing to show how his body transformed after a masculinization procedure that he nicknamed the “Dorito chip” for the way it changed his shape. His surgery was covered by an LA Care plan he obtained through Covered California, the marketplace set up under the Affordable Care Act for Californians to get insurance.
“I’m privileged to be here,” Wright said of his life in California. “And I think about how people are going to have to come here… to be able to have a medical transition.”
California leaders have sought to protect access to such procedures for transgender people. State-licensed health plans must provide transgender people with medically necessary gender-affirming care. Doctors who provide such care in California are legally protected from laws that criminalize such care in other states.
But experts and advocates said even in California, access to gender-affirming care could be undermined by federal action as Trump returns to power for a second time. child abuse. State lawmakers have vowed to oppose efforts to hinder gender-affirming care, which could exacerbate future battles in court.
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“I’m not going to sit here and say that California can fend off every despicable federal attack on transgender people,” said Sen. Scott Wiener (D-San Francisco), who supports protections for transgender patients and their doctors. “But we are going to do everything we can to stand up for the community.”
President-elect Trump has pledged to pressure Congress to block the use of federal funds for gender-affirming care, including surgery, a position also reflected in the Republican Party’s platform. Exactly how a ban will be imposed remains to be seen, but experts say the Trump administration could model it after the Hyde Amendment, which for decades has largely banned the use of federal funds for abortion.
Eliminating federal funding would have far-reaching consequences because “virtually every corner of the health care system contains some element of federal funding,” said Kellan E. Baker, executive director of the Whitman-Walker Institute, which conducts research and advocacy in the field of healthcare. Its consequences “will hit hardest on those least positioned to afford the health care they need.”
He said those affected include 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 penchant for funding things that go above and beyond what Medicaid will do nationally,” such as supporting low-income Californians regardless of their immigration status, said John Baackes, CEO of LA Care, a health care plan that serves more than 2 people. million people in LA County. “The state could say, ‘OK, we’ll fund it.'”
Mars Wright sits in a small studio space in his apartment with his older dog Lucy. (Gina Ferazzi/Los Angeles Times)
Trump is also expected to pursue changes to Medicaid that would reduce federal spending, which could put financial strain on California if it wants to continue other existing programs under Medi-Cal, the state’s Medicaid program. But advocates said that because transgender people make up a small share of the population — estimated at 0.6% of U.S. teens and adults in one analysis — bearing the cost of gender-affirming care would not be a major expense.
Experts say states have wide discretion when it comes to their spending, but Trump has previously tried to use Medicaid to pressure California over its policies. 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 failed, but it could indicate how his administration might try to pressure California. A Trump representative did not respond to an email seeking comment on that possibility.
At clinics at the Los Angeles LGBT Center, anxious patients wonder, “Do I have to get hormones for a year now? Do I have to do all the surgeries I’ve ever wanted to do?” said dr. Kaiyti Duffy, the 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 would not only ban the use of federal dollars for gender-affirming care, but also ban providers of such care from receiving federal funding.
Some of his proposals specifically target gender-affirming care for young people, which has been a focus for groups who argue it harms children who do not understand the implications of such treatment. Greg Burt, vice president of the California Family Council, called it “the biggest lie this state has ever perpetrated against our young people, to tell children that it is 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, a mother said puberty blockers had been a “pause button” that eased the despair for her transgender child, now 14, and gave the family time to figure out what he needed. The military family, which relies on federally funded Tricare insurance for servicemembers, consulted doctors and ultimately proceeded with hormone treatment with testosterone.
“At each stage of medical care, he became more and more himself,” said the mother, who asked not to be identified to protect her teen’s privacy. “He switched from still and silent to active, alive and thriving.”
If her child can’t get such care in California, she says, they will make plans to leave the country.
Trump has called for a ban on gender-affirming care for young people in every state, calling it mutilation. During the campaign, Trump said he would seek to remove from Medicaid and Medicare any health care provider who “participates in the chemical or physical mutilation of minors.”
The Medicare and Medicaid programs are “the biggest lever the federal government has because hospitals get so much money from them,” said Julianna S. Gonen, director of federal policy at the National Center for Lesbian Rights. The threat of losing it “is so serious that hospitals are likely to comply before they risk being terminated from the programs.”
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Experts said the White House could also seek a federal determination that such care is dangerous or experimental, which would resonate with federally funded programs.
Alejandra Caraballo, a clinical instructor at Harvard Law’s Cyberlaw Clinic, told many healthcare providers, “If there’s a risk of losing your federal funding — meaning you can operate — it’s easier to just drop a trans patient.”
The Trump administration could also roll back federal regulations that prohibit health care providers from denying care to transgender patients if the same type of care is provided to others. However, California has its own rules that prohibit health plans from denying care based on gender identity.
Some believe the Trump administration could also try to restrict hormonal therapy through Food and Drug Administration regulations. However, Amanda McAllister-Wallner, interim director of the consumer advocacy group Health Access California, said it can be difficult to determine who provides “gender-affirming care” because such interventions are also used for other conditions.
“It’s not necessarily clear: Was this service provided because of someone’s diagnosis of gender dysphoria or for some other reason?” said McAllister-Wallner.
A survey of insured patients published in JAMA Network Open found that the number of breast reductions for trans youth in the past year far exceeded the number of breast reductions for boys who are not transgender. Researchers said surgeries for transgender teens were “rare and almost entirely breast-related procedures” and found no surgeries on trans youth 12 or younger.
Before Election Day, Bamby Salcedo planned to push for improvements in gender-affirming care through a Medi-Cal initiative called CalAIM. The election has put those efforts on the back burner, says Salcedo, president and CEO of the TransLatin@ Coalition, an advocacy group founded by transgender women in LA.
In its aftermath, Salcedo continued to push for a budget allocation in LA County to support the needs of transgender people, saying local government must act. And she was also busy planning a fashion show to celebrate her organization’s fifteenth anniversary, calling it an opportunity “for that one evening to bring joy to our people.”
“One way or another, we will get through this,” she said.
Mars Wright poses for a photo. Wright was able to undergo body masculinization surgery through Covered California insurance (Gina Ferazzi/Los Angeles Times)
Wright was among the designers showcased at the event. Before undergoing his surgical procedure, he said, “I was afraid of dating. I was afraid to wear clothes I liked. I was afraid to go to the beach.’ Now he joked: “I can’t keep my shirt on.”
“I’m in a place where I enjoy being trans.”
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This story originally appeared in the Los Angeles Times.
