This is the second story in a two-part series looking at health care available to transgender youth in Vermont. The first story “Vermont positioned to become gender-affirming care haven for New Hampshire families” can be found here.
Step by step, since the start of his second term, the administration of President Donald Trump has moved to use insurance programs overseen by the federal government as a tool for blocking gender-affirming care for minors nationwide.
It started with a presidential executive order in January that declared the new policy of the United States would be that the government “will not fund, sponsor, promote, assist or support” youth transitioning “from one sex to another.” Since then, blocking minors from accessing the broad suite of care that falls under the umbrella of gender-affirming care, like hormone replacement therapy, puberty blockers, or gender-affirming surgery, has become a focus for both political rhetoric and activity by federal agencies.
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by Olivia Gieger
October 20, 2025, 10:56 amOctober 21, 2025, 9:21 am
While people look to Vermont as a place buffered from the fallout of federal attacks on health care for transgender youth, advocates and providers in the state remain on high alert in order to maintain access to that care. State law does protect health care providers and requires that people not be denied care because of their gender identity. But federal rules, particularly governing insurance coverage, may make that more complicated.
Mike Fisher, the state’s health care advocate, stressed that although the atmosphere feels more fraught now, people should know that access to gender-affirming care for minors remains available in Vermont.
“Vermont law is clear on legally protected care,” he said. “At least in today’s legal landscape, the status quo is maintaining.”
In Vermont, most young people can access this kind of care through UVM Medical Center’s Transgender Youth Program. PlannedParenthood of Northern New England and other providers or therapists also offer some of the services that fall into gender-affirming care’s wide net. At UVMMC, patients can meet with a clinician to receive hormonal interventions, like puberty blockers or hormone replacement therapy. For surgeries, the hospital refers patients out of state.
Vermont has strong shield laws that protect those who provide and receive gender-affirming care from threats or civil or criminal charges from another state. The shield laws also classify gender-affirming care as an essential part of health care that in-state health insurance plans must cover.
So even as the Trump administration tries to unravel access to gender-affirming care, Vermont’s existing state law requires that this access remain in place.
Essential health care
A major player in the Trump administration’s efforts is the Centers for Medicare and Medicaid Services, or CMS, which oversees and funds, entirely or in part, the operations of both federal insurance programs. The agency also sets regulations that govern the private insurance markets and subsidies put in place by the Affordable Care Act.
Through official communication and rulemaking, leaders at CMS have tried to enact new policy through the leverage of their control over more than $2 trillion in Americans’ annual health care spending.
The University of Vermont Medical Center in Burlington on Nov. 23, 2020. File photo by Glenn Russell/VTDigger
This June, CMS finalized a set of rule changes that made it more difficult to access many types of care under plans bought on the Affordable Care Act marketplace. One of those changes allows private insurers selling plans on the market to not cover gender-affirming care by removing it from the list of “essential health benefits.” Those are the package of benefits that all ACA marketplace plans are required to cover. So insurance companies are not prevented from covering this care, but they are no longer required to do so.
In July, Vermont Attorney General Charity Clark joined 20 states in a lawsuit challenging the rule.
“The Trump Administration cannot violate the law, and we will fight attempts to roll back coverage for Vermonters, including any attempt to take away coverage for gender-affirming care under the ACA,” Clark said in a July press release at the time.
Vermont’s anti-discrimination law, though, prohibits insurers from discriminating against covering this care. Functionally, it ensures that in-state insurance companies keep this care protected.
Vermont is one of five states, alongside California, Colorado, New Mexico and Washington, which the federal rule identifies as specifically including coverage for some gender-affirming care as part of the marketplace insurance standard.
Jason Williams, who leads UVM Medical Center’s external communications, said that the hospital is tracking how private insurance covers hormone replacement therapy — or doesn’t.
Some private insurers have prematurely ended coverage for this gender-affirming care, Williams said. For employer-sponsored insurance plans, the state has no power to tell a company to cover the drugs, since those plans are managed federally.
For one Washington County family, the uncertainty of coverage for gender-affirming care has already become a reality: When Michelle, whose last name VTDigger is not using to protect her family’s privacy, took her daughter for hormone injections in July, their insurance covered it. On Oct. 6, she was denied coverage by her primary insurer Blue Cross Blue Shield of Vermont. Her secondary insurance, Vermont Medicaid, followed suit because her primary denied it. The insurer has since denied the appeal she filed, Michelle said. She cannot afford the cost of the hormones without insurance, and thus, her daughter is switching to a different type.
Sharon Segel, a nurse volunteer at the People’s Health and Wellness Clinic in Barre, stands in front of a rainbow wall in the waiting room that celebrates the launch of free gender-affirming health care to all residents aged 18 and above in Central Vermont. Photo courtesy of Daniel Barlow
Gina Brittain, communications and marketing manager for Blue Cross and Blue Shield of Vermont, did not comment on this case specifically, but told VTDigger that “Blue Cross Vermont maintains its longstanding medical policy to support gender affirming care. This support extends to members under the age of 18 who meet the medical necessity and documentation requirements outlined within our Gender Affirming Services Corporate Medical Policy.”
Medicaid rules
Many providers and advocates also worry about other pathways the Trump administration may take to pull back insurance coverage for gender-affirming care.
In particular, they worry about how CMS is targeting state Medicaid agencies’ coverage of the care for minors. In April, federal regulators sent a letter to the state agencies who operate Medicaid warning that “growing evidence” shows gender-affirming care for minors should not be covered by the insurance program. Yet, Vermont law requires its Medicaid program to do so.
Monica Allard. Photo via the ACLU
If CMS were to finalize rules that withhold federal Medicaid funds from being used for gender-affirming care, Vermont Medicaid would need to use state funds to cover that care, explained Monica Allard, a staff attorney with the ACLU of Vermont. The costs of covering this care would be relatively small, she added.
“The disruption of funding itself doesn’t disrupt the obligation to provide the care,” Allard said. “A change to the rules around Medicare and Medicaid funding would only mean that the funds would need to come from a new source, not that it would be illegal to provide that care.”
The biggest concern, however, for Williams at UVM Medical Center and others, came in the form of a rule title briefly posted to the Centers for Medicare & Medicaid Services website in August.
CMS regularly issues rules called “conditions of participation.” These are standards the federal government says a health care provider must meet in order to participate in Medicare and Medicaid programs. If a hospital or a clinic doesn’t meet those conditions, it cannot bill or receive funding for any services to Medicare or Medicaid patients. It disqualifies a provider from billing the program for even the most routine of check-ups.
The proposed rule that CMS posted would disqualify providers from participating in Medicare or Medicaid entirely if they are also providing gender-affirming care to minors. Though just a title was published and the rule has not been officially written, the chill it has left for providers remains.
“At the end of the day, we can expect that this is going to be included [as a proposed rule].” Williams said.
But the hospital’s leaders also predict that there could be a long lag between when the rule is proposed and when it will be actually implemented. Once CMS proposes a rule, the Office of Management and Budget reviews it and a public comment period opens.
“We can also expect that it’s going to be litigated, and there’s a good chance that there will be judicially-issued pauses,” Williams said. “When something [does] come out, if something comes up, the words are really going to matter.”
For instance, much of the language the federal government has used to target trans health care has focused on surgical care, which UVM Medical Center already does not provide for minors, though it does for adults.
Ultimately, if the condition does come to pass, “the implications far exceed gender-affirming care,” Williams said. Nearly two-thirds of the patients the medical center sees receive Medicare and Medicaid. A condition restricting a hospital from receiving CMS reimbursements would force it to choose between providing the entire range of care to that entire population of patients or gender-affirming therapy for minors.
“If we wouldn’t be able to see [Medicare and Medicaid patients], that would spell the end for any health system,” Williams said.
The Patient Pavilion at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, catches the evening light on May 28, 2025. Photo by James M. Patterson/Valley News
Keeping care accessible
Even if the change in conditions of participation brought the end of gender-affirming care for minors at the state’s biggest hospital, it would not mean the end of the services in the state, said the ACLU’s Allard.
“The Trump administration knows it doesn’t have the power to unilaterally ban gender-affirming care, so instead, it is trying to change the rules for receiving Medicare and Medicaid funding to threaten access to health care for everyone unless providers abandon trans youth,” she said. “Vermont’s responsibility to provide access to affordable gender-affirming health care would not change based on new federal Medicare and Medicaid rules,” she said.
To cover the care, though, a new and separate funding source — and likely a new provider — would need to be set up and set aside, Allard said. That could mean a public-private partnership or a combination of Vermont state funds, private health insurance, philanthropy and patients self paying. Allard noted that Massachusetts, for instance, allocated funds for gender-affirming care in its fiscal year 2026 state budget.
Williams echoed these possibilities. “Is it a new organization that comes out of this? Is it an existing organization that doesn’t care about losing participation in Medicare or Medicaid?” he said.
“The thing that will ensure care is able to be provided, (and) by what entity, really will be the support of our community,” Williams added. “If you can’t receive reimbursements from Medicare or Medicaid, then private sources of funding, like philanthropy, will have to ensure that whoever’s providing that care is able to continue to provide.”
Jessica Barquist, a spokesperson for Planned Parenthood of New England, noted that the provider already runs a donor-supported fund to help those who need it access and afford care.
If an institution — be it an insurer or the state itself — were to deny someone care because of their gender identity, it would be a violation of Vermont’s anti-discrimination laws, Allard added. She urged providers to resist pre-emptive or voluntary compliance with these federal impulses.
“It’s completely likely and possible that a real change like this could be challenged and potentially halted,” she said. “Leaders in state government and health care institutions are, I think, aware, and should continue to be aware of the risks of preemptive compliance with these sort of questionable federal directives.”
Dana Kaplan, executive director of Outright Vermont, in Burlington on May 18, 2023. File photo by Glenn Russell/VTDigger
Dana Kaplan, the director of LGBTQ+ resource organization Outright Vermont, said that his organization has been closely monitoring the actions coming out of the federal government. He said there has been a degree of confusion about what is legal and what is safe — and what will be accessible if federal actions do restrict access to care.
“I think we’ve talked more to the Attorney General’s Office in Vermont this year than we have in any other year,” he said. The organization has also been in “deep communication” with leadership at UVM Medical Center to discuss how they can ensure that resources and services continue to reach the young people who need them “if the worst comes to bear,” he said.
Should that come to bear, Kaplan is clear that his community will play a strong role in building out its own alternatives and pathways to access care. “There’s a real question, which I think marginalized communities have held for decades, which is, ‘How do we create our own safety? How do we create our own care?’” he said.
Already queer advocacy groups are facing the reality of these federal changes hitting close to home. Just last week, the Pride Center of Vermont, which primarily supports adults in the LGBTQ+ community, had to close its doors to service due to a loss of federal and state funding.
For now, advocates and providers should continue to explore creative pathways and be ready to respond to the specific language of federal directives, Kaplan said. The most important thing, though, will be continuing to ensure that young people continue to receive the care they need, he said.
“I think that part of what we’re all trying to navigate right now is to shore up the practices and policies that we do have in place, or to figure out how to ensure that we’re not moving backwards in places where we have already made strides,” Kaplan said.