Millions of Americans are expected to lose health care coverage through President Donald Trump’s “one big, beautiful” tax and spending law — and LGBTQ+ Americans, who rely heavily on social services due to high rates of poverty and disability, are among those who will be most impacted. Experts say that widespread loss of health care, coupled with rising discrimination and fewer workplace protections, will create a worst-case scenario for LGBTQ+ rights.
“These support programs are being cut amid an increased environment of hostility towards LGBTQ+ people,” said Brad Sears, distinguished scholar of law and policy at the Williams Institute at UCLA School of Law. “We’re really seeing this coming together … of different pressures that are going to lead to poverty and unemployment among LGBTQ+ people.”
The law issues extensive cuts to Medicaid and the Supplemental Nutrition Assistance Program (SNAP) — two programs designed for low-income and disabled Americans that many LGBTQ+ people need to survive. LGBTQ+ adults are twice as likely as non-LGBTQ+ adults to use Medicaid as their main insurance, according to the Williams Institute, and are more likely to experience food insecurity and rely on SNAP benefits. Medicaid is also the primary insurance for Americans living with HIV.
Medicaid cuts will profoundly impact disabled LGBTQ+ adults and those with low incomes, according to a recent Williams Institute report, as well as those raising children. People of color, transgender adults, and cisgender lesbian and bisexual women will be especially impacted.
“It’s a sort of death by a thousand cuts,” said Katie Keith, director of the center for health policy and the law at the O’Neill Institute at Georgetown Law.
The law attaches more documentation and a work requirement to Medicaid, while putting more costs on hospitals when patients don’t have insurance and can’t pay. People will lose coverage altogether or have less comprehensive coverage, Keith said.
The law, which goes into effect next December, cuts federal spending on Medicaid and the Children’s Health Insurance Program by more than $1 trillion over the next decade. The Congressional Budget Office has estimated that 11.8 million Americans will lose health care coverage over the next decade due to the law’s Medicaid cuts. Roughly 1.8 million LGBTQ+ adults use Medicaid as their primary health insurance, including more than 1.2 million lesbian and bisexual women, per the Williams Institute.
The law creates an 80-hours-a-month work requirement in order to access Medicaid — although recipients can volunteer for 80 hours a month instead or enroll in at least a part-time education program. These requirements go into effect in early 2027. Exceptions are granted to disabled adults, pregnant women — the law only refers to women, leaving out pregnant trans men or nonbinary people — and parents of young children, but experts say it’s unclear how meaningful these exceptions will be and whether patients are aware of them.
“The Congressional Budget Office has really pinpointed work requirements as what’s going to lead to disenrollment,” Sears said. “The red tape, the bureaucracy, disenrolls people who would otherwise be eligible.”
Medicaid recipients will now have to file paperwork every six months to prove that they are working or volunteering for 80 hours a month, or to request an exemption, said Lindsey Dawson, director of LGBTQ health policy at KFF. These requirements, which have never been issued on a national level before, are expected to dramatically reduce Medicaid enrollment, she said. If someone is already navigating difficult circumstances, like an unstable living situation or surviving on minimal income, they probably won’t be able to keep up with additional paperwork.
The 19th spoke with several LGBTQ+ people on Medicaid who doubt that work requirement exceptions for disabled people and parents will help them keep their coverage, even though they qualify for now. They still expect to lose their health care due to the burdens of this new paperwork, or because of how much money hospitals are expected to lose under this new law.
“Why does it have to be like this? It really feels overwhelming, because it doesn’t seem like it should be this hard to make sure that people can go to the doctor,” said Frankie Brletich, a 30-year-old nonbinary person living in Philadelphia.
They know how hard it can be to navigate the red tape of health insurance, prescriptions and doctor’s visits as a disabled person. They expect these new Medicaid work requirements to make it worse, and to ultimately discourage disabled people from seeking out coverage altogether. Under Trump’s new tax law, Brletich has been worried about losing the Medicaid coverage that took them so long to get.
They have been unable to work for over a year, as they experience chronic fatigue, chronic pain and have a history of mental illness. They applied for Medicaid in December when they left their job and didn’t get approved until March this year. In the meantime, they were uninsured. They ran out of psychiatric medications as well as their testosterone prescription, leaving them in a depressive state as their mental health declined. As they left their employer-sponsored private insurance and switched to Medicaid, they had to deal with pharmacy mishaps, change medical providers and get a new therapist.
Soon, they will face even more red tape to access the Medicaid coverage that they sorely need. Meanwhile, they are working with a lawyer to apply for Social Security Disability Insurance, which sends monthly payments to people with a disability that hinders their ability to work. The first time they applied for SSDI, they were denied. They’re appealing that decision.
Although Trump’s new tax and spending law includes exceptions for disabled Americans in its work or volunteer requirements, the law puts the burden of accessing those exceptions onto disabled people like Brletich.
“There’s still the administrative burden of paperwork that is then put on to me to re-up every time and to constantly prove that I am ‘still disabled,’” they said.
The Movement Advancement Project, which tracks LGBTQ+ policy, estimates that between three to five million LGBTQ+ people in the United States have disabilities, including 2 in 5 transgender adults. This group faces steep barriers to health care access, due to medical discrimination and lower rates of health insurance. LGBTQ+ people are also more likely to experience mental health conditions that impact daily life, compared to the general population.
Although these Medicaid cuts will harm many Americans, Keith is especially concerned about how it will impact transgender people, since health care access for this group is being threatened on multiple fronts. Starting in 2026, insurance sold on the individual and small-group marketplace will no longer cover gender-affirming care, which is expected to raise costs overall. In Congress, Republican lawmakers had planned to prohibit Medicaid from covering gender-affirming care for transgender adults and minors altogether, but that provision was dropped in the final version of the spending bill.
“Any time you are fraying the social safety net, as they are doing here, you are inevitably going to hard vulnerable populations, including transgender communities,” Keith said.
Another Medicaid recipient in Washington state told The 19th that she believes carve-outs for work exceptions will still be a significant barrier for disabled Americans. She asked to remain anonymous due to prior experiences receiving death threats for her advocacy as a trans woman.
“If you have a significant disability or multiple disabilities, if somebody cuts you off of your health care and then sends you a letter saying, ‘By the way, there’s this administrative process by which you can get back on’ — it is the people with disabilities that are going to be least able to navigate that system, including me,” she said.
As a disabled woman in her mid-50s with an annual income of about $8,000, she would not be able to see a doctor without Medicaid. She enrolled in Apple Health, the expanded Medicaid program in Washington, in January. Until that point, it had been almost five years since she had had health insurance or seen a doctor.
Due to a combination of factors — depression, severe social anxiety, and chronic pain — applying was too difficult. And she couldn’t see a doctor without insurance, because paying out of pocket was just not possible. So she avoided medical care, and also largely avoided leaving the house. If she loses coverage again, it may take her another four years to re-enroll, she said; that’s how long it took her to navigate the process the first time.
Costs for states to run their Medicaid programs are also expected to rise, Dawson said, as the new law effectively decreases the revenue that states can generate from their programs. Some states may have to shrink their Medicaid programs if they can’t afford to run it under the new law.
“We have not historically seen changes to our health care system that would result in coverage losses like this before,” she said. “It’s really a significant rollback in federal support for health coverage, and I think states will be faced with tough choices.”
Considering the scope of these cuts, Cassidy Vare, a Philadelphia resident who relies on Medicaid coverage for her and her two children, is not feeling confident about the future of health care in Pennsylvania. Since her children are 13 and 5 years old, and she’s currently attending school, she should be exempt from the law’s strict work requirements. Regardless, she is terrified of losing care. Hospitals in the state are expected to lose about $4.5 billion per year over the next decade because of Medicaid cuts, per a local news outlet.
“We have some time to figure out what we’re going to do next, but … a year from now looks kind of scary,” she said. Without Medicaid, Vare would need to drop out of her master’s program to get a job with health insurance — which would disrupt her plan to secure a more stable and high-paying career for her family.
Vare, as well as other Medicaid recipients that The 19th spoke with, had no knowledge of any exemptions for parents in her situation written into the new law until The 19th informed her about it. From her perspective, health care is being taken away, and her family’s future is at stake.
“It looks like Medicaid is going away, even if they’re pretending that it’s still going to exist,” she said. “I don’t know whether my state will be able to cover my insurance or not.”
These fears are not unfounded, Dawson from KFF said. State Medicaid programs may change, and people are expected to lose coverage on a large scale. That said, anyone eligible for Medicaid coverage under the new law should pursue that access however they can, she said.
“When you hear that the federal government itself expects 12 million people to lose insurance coverage, it’s hard not to imagine what will happen if you’re one of those individuals,” she said.
Great Job Orion Rummler & the Team @ The 19th Source link for sharing this story.
