How have recent federal or court rulings affected access to gender-affirming care under the ACA?
Executive summary
Federal and court decisions since 2024 have produced conflicting effects on ACA protections for gender-affirming care: several federal courts have found that categorical exclusions violate Section 1557’s sex‑discrimination bar, while the Department of Health and Human Services (under the 2025 administration) rescinded prior guidance and finalized rules that remove gender‑affirming care from Essential Health Benefit protections and limit HHS enforcement (see court wins affirming Section 1557 claims [1] [2] and the HHS rescission and EHB rulemaking [3] [4]). These parallel trends mean access now depends heavily on which courts, states, insurers, and federal policies prevail in ongoing litigation [5] [4].
1. Two legal currents: courts enforcing Section 1557 vs. new federal rulemaking
Since 2024, trial and appellate courts have repeatedly held that categorical insurer or state plan exclusions for gender‑affirming services violate Section 1557’s nondiscrimination protections when those exclusions treat transgender patients differently than comparable cisgender patients (Fourth Circuit affirmance and district court wins) [1] [2]. At the same time, HHS in 2025 rescinded Obama/Biden‑era OCR guidance on gender‑affirming care and finalized regulatory changes that prohibit treating “sex‑trait modifications” as an ACA Essential Health Benefit (EHB), a step that can reduce statutory protections and increase out‑of‑pocket costs if insurers drop or narrow coverage [3] [4].
2. What the courts have done: Section 1557 as an enforcement vehicle
Federal courts have sided with plaintiffs who argued that exclusions of gender‑affirming care are sex‑based discrimination under Section 1557, enjoining exclusions and ordering coverage in multiple contexts — including state employee plans and insurer policies — and the Fourth Circuit affirmed trial rulings to that effect [1] [2]. Legal filings and briefs emphasize that Section 1557 incorporates Title IX and other statutes, which the courts have used to find disparate treatment when plans impose rules on transgender people that they do not impose on cisgender people [2] [6].
3. What the executive branch has done: rescissions, executive orders, and EHB rules
In 2025 HHS’s Office for Civil Rights formally rescinded its 2022 OCR Notice and Guidance on gender‑affirming care, citing new executive orders and recent legal decisions as reasons to change course; OCR signaled it would not continue prior enforcement approaches tied to gender identity under Section 1557 [7] [3]. Separately, HHS finalized a Marketplace rule removing “sex‑trait modification procedures” from the list of EHBs, which could allow insurers to omit or limit such services in ACA plans starting with plan years affected by that rule [4] [8].
4. The practical impact: patchwork access and higher costs likely
Removing gender‑affirming care from EHBs means marketplace plans would no longer have the same federal obligations (like limits on annual/lifetime caps or cost‑sharing rules) for those services; independent experts and state analysts warn that could lead insurers to drop coverage or shift costs to patients and states [4] [8]. By contrast, favorable court rulings force particular plans or insurers to cover care under Section 1557 where courts find discrimination; those rulings create rights for plaintiffs but do not by themselves nullify federal rule changes or blanketly guarantee coverage nationwide [1] [2].
5. Where enforcement and litigation collide: why the result will vary by forum
HHS’s policy changes reduce the agency’s appetite and regulatory tools to pursue Section 1557 claims tied to gender identity, and HHS has even dropped certain appeals — a development that lowers the immediate risk of federal enforcement for entities denying care [9] [7]. Litigation by states and private parties continues, including multi‑state suits challenging the Marketplace rule and district court injunctions blocking parts of executive orders, meaning outcomes will turn on appellate rulings and injunctions [5] [4].
6. Who this helps and who it hurts: implicit agendas and consequences
Courts that enforce Section 1557 protect individuals against discriminatory exclusions on a case‑by‑case basis [1] [2]. The executive branch changes reflect an explicit agenda to constrain federal recognition of gender identity protections and to limit federal funding or EHB obligations tied to gender‑affirming care — a policy choice that advances a political goal of reducing federal coverage mandates even as it cites legal uncertainty [7] [4]. States with their own mandates or protective laws will continue to provide stronger access where those statutes apply [10] [5].
7. Bottom line and the road ahead
Current sources show a bifurcated landscape: judicial rulings have created enforceable wins for plaintiffs under Section 1557 in multiple cases [1] [2], but HHS’s rescission and EHB rulemaking have materially weakened national regulatory protections and could produce reduced coverage and higher costs unless courts or Congress intervene [3] [4]. Ongoing litigation by states and private parties will determine whether courts check the new federal rules or whether the administrative changes stand — available sources do not mention a definitive nationwide resolution as of the documents provided [5] [4].