HHS Previews Future Restrictions on Care for Trans Youth under Medicare and Other Federal Funding

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Three agencies from the U.S. Department of Health and Human Services (HHS)—the Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA)—have issued communications in response to President Trump’s (EO) directing Executive Branch agencies to work towards shutting off access to care nationwide for transgender individuals under the age of 19.

None of these communications defines concrete directives or guidance for impacted stakeholders. Rather, they underscore the administration’s desire for providers to cease gender-affirming surgeries and medications for youth, compile evidence in favor of the administration’s position (including recent policy changes in certain other countries narrowing gender-affirming care for youth), and preview how these agencies may seek to penalize providers that continue offering these treatments. Given ongoing litigation on the EOs—including court orders blocking the administration from implementing certain aspects of the EO—it is likely further action by HHS to implement the EO and restrict access to care for transgender youth will be subject to legal challenges.

: Conditions of Participation. This memo was issued by CMS’ Center for Clinical Standards and Quality, which is responsible for clinical policies and provider oversight—including the Conditions of Participation (COPs)—for Medicare and Medicaid. CMS characterizes the memo as a “reminder” of federal requirements for hospitals to “serve all patients, especially children, with dignity and adherence to the highest standard of care that is informed by robust evidence and the utmost scientific integrity.”

The memo does not announce any policy changes, but previews that “CMS may begin taking steps in the future to align policy, including CMS-regulated provider requirements and agreements”—likely consistent with President Trump’s directive to amend the COPs so that a provider will be unable to participate in Medicare or Medicaid if they offer gender-affirming care to transgender youth – regardless of whether the young person is covered by Medicare, Medicaid, or some other form of insurance.

Historically, rulemaking has been required to implement substantive changes to the COPs. However, a suggests that HHS agencies—including CMS—may now be more willing to issue final rules without first seeking public comment. It remains to be seen whether CMS would seek to do so in this instance, and if so, whether that decision would hold up in court.

HRSA Letter: CHGME and Other Funding. Citing the same concerns as the CMS memo, HRSA announced its plans to review its policies, grants, and programs to ensure alignment with the President’s stance on gender-affirming care for youth. The letter specifically calls out the Children’s Hospitals Graduate Medical Education (CHGME) Payment Program, which awarded $367.2 million to children's hospitals in fiscal year 2024 and support training for of all general pediatrics residents nationwide.

Congress has previously debated restrictions on these dollars linked to bans on care for transgender youth, but they were not adopted. HRSA suggests it may adjust or cancel future grants depending on policy changes the agency makes related to the medical treatments discussed in CMS’ alert. If so, children’s hospitals would face a choice between continuing to receive federal funding or providing care to trans youth.

These actions would fulfill the President’s directives for HHS to restrict grants and medical education funding for providers that offer gender-affirming medications and surgery to youth. Those specific directives that are currently blocked under two separate court orders ( and ), which may help to explain why HRSA is previewing—rather than initiating—actual policy change.

SAMHSA Letter: Behavioral Health Grants. Like HRSA, SAMSHA announces it will review its policies, grants and programs and may begin taking steps in the future to update its policies, including adjustments to or cancelling future grants. SAMHSA funds are used to support mental health and substance use disorder prevention, treatment and research. As with HRSA, court orders currently prohibit SAMHSA from restricting grant funding based on a provider’s provision of gender-affirming medications or surgery.

The EO uses the phrase “chemical and surgical mutilation” to refer to medication- and surgery-based treatments for gender dysphoria but clarifies that this term is intended to be synonymous with “gender affirming care.” 

Puberty blockers and gender-affirming hormones are rarely prescribed to transgender adolescents. A recent study of private insurance claims over the last five years showed that less than 0.1% of adolescents received prescriptions for puberty blockers or hormone therapy. Another study on privately insured claims found that there were no gender-affirming surgeries conducted on individuals aged 12 years and younger, and procedures on individuals 12-17 were rare. 

Interim final rules can be issued without notice and comment in cases of “good cause” if traditional procedures would be “impracticable, unnecessary, or “contrary to the public interest.” A 1971 HHS policy directed HHS agencies to use this exception “sparingly, as for example in emergences [sic] and in instances where public participation would be useless or wasteful because proposed amendments to regulations cover minor technical matters.” HHS has rescinded that policy, directing agencies to use the good cause exception “in appropriate circumstances.”

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