Technical corrections only. The changes between v2 and v3 reflect the bill's procedural status, indicating it passed the House and was referred to the Senate. There are no substantive policy changes in the legislative text.
Do No Harm in Medicaid Act
- Sponsor
- Rep. Crenshaw, Dan [R-TX-2]
- Committees
- Finance Committee (primary)
- Last action
- Dec 18, 2025
Bottom line
H.R. 498 would eliminate federal Medicaid reimbursement for gender-affirming care for minors, shifting costs to states or individuals and restricting access to such medical services for Medicaid-eligible youth.
What it actually does
This bill amends title XIX of the Social Security Act to prohibit the use of federal Medicaid funds for "specified gender transition procedures" for individuals under 18 years of age. It defines these procedures to include a wide range of surgeries, implants, and hormone therapies intended to change an individual's body to no longer correspond to their biological sex. Exceptions are made for precocious puberty, medically verifiable genetic disorders of sex development, or procedures necessary to address conditions caused by previous gender transition procedures or to prevent imminent death or major bodily function impairment, excluding the alleviation of mental distress.
Proponents argue
Proponents argue that this bill protects minors from irreversible medical procedures, asserting that children are not mature enough to make such life-altering decisions. They contend that federal taxpayer funds should not be used for treatments that they view as experimental or potentially harmful for developing individuals, emphasizing a precautionary approach to medical interventions for gender dysphoria in minors. Supporters also highlight the importance of parental consent and the need to ensure medical care aligns with biological sex.
Opponents contend
Opponents contend that this bill interferes with critical medical decisions that should be made between patients, their parents or legal guardians, and their healthcare providers. They argue that denying medically necessary, evidence-based gender-affirming care to transgender youth can lead to severe negative health outcomes, including increased rates of depression, anxiety, and suicide. Critics also view the bill as discriminatory, targeting a vulnerable population and infringing upon the rights of transgender minors to access healthcare.
The bill is concise and relatively straightforward, making it accessible for an informed reader to evaluate its core provisions within a short timeframe.
Section 2(a), amending Section 1903(i) of the Social Security Act
Prohibition of Federal Medicaid Funding for Gender Transition Procedures for Minors
This provision amends the Social Security Act to explicitly prohibit federal Medicaid matching funds for any amounts expended by states for "specified gender procedures" provided to individuals under 18 years of age. This includes not only the direct cost of the procedures and drugs but also any administrative costs associated with a state program that furnishes these services to minors. This means states would not receive federal reimbursement for such expenditures.
Supporters argue
Proponents argue that this prohibition ensures federal taxpayer dollars are not used to fund procedures for minors that they consider medically controversial or ethically questionable. They believe it aligns federal spending with a policy of protecting children from irreversible medical interventions.
Critics contend
Opponents contend that this provision directly interferes with states' abilities to provide comprehensive healthcare coverage under Medicaid and forces states to either absorb the full cost of medically necessary care or deny it to vulnerable youth. They argue it is a federal overreach into state healthcare policy.
Tradeoffs
This provision balances federal fiscal control and policy preferences against state autonomy in healthcare provision and access to care for a specific population. It creates a tension between federal funding directives and state-level medical coverage decisions.
Section 2(b), adding new subsection (kk) to Section 1905 of the Social Security Act
Definition of 'Specified Gender Transition Procedures'
This section provides a comprehensive definition of what constitutes "specified gender transition procedures" that would be ineligible for federal Medicaid funding. It includes a detailed list of surgeries such as castration, mastectomy, vaginoplasty, and phalloplasty, as well as the placement of various implants. It also covers the administration of medications like puberty blockers (gonadotropin-releasing hormone analogues) and supraphysiologic doses of testosterone, estrogen, or progesterone, when performed to intentionally change an individual's body to no longer correspond to their biological sex.
Section 2(b), adding new subsection (kk)(B) to Section 1905 of the Social Security Act
Exceptions to the Prohibition
This provision outlines specific exceptions where federal Medicaid funding would still be permitted, provided there is parental or legal guardian consent. These exceptions include puberty suppression for precocious puberty (when puberty begins unusually early), and medically necessary procedures to correct for genetic disorders of sex development (e.g., intersex conditions), abnormal sex chromosome structure or hormone production, or to treat infection, disease, or injury caused by a previous gender transition procedure. It also allows procedures to restore or reconstruct the body to correspond to the individual's sex after previous gender transition procedures, but explicitly excludes procedures performed solely for the alleviation of mental distress.
Section 2(b), adding new subsection (kk)(C) to Section 1905 of the Social Security Act
Biological Definition of 'Sex'
This provision defines the term 'sex' for the purposes of the bill as either male or female, based on biological determination. It specifies that 'female' refers to an individual who naturally has, had, will have, or would have (but for anomaly or accident) the reproductive system that produces, transports, and utilizes eggs for fertilization. Similarly, 'male' refers to an individual who naturally has, had, will have, or would have the reproductive system that produces, transports, and utilizes sperm for fertilization. This biological definition underpins the entire prohibition on procedures intended to change an individual's body to no longer correspond to this defined sex.
The prohibition on federal Medicaid funding extends not only to the direct costs of specified gender transition procedures and drugs for minors but also to "any amounts expended for the administration of a State program that furnishes specified procedures and drugs to individuals under 18 years of age."
Section 2(a)(3), amending Section 1903(i) of the Social Security Act
Why it matters:This inclusion is standard legislative practice for ensuring comprehensive application of funding restrictions, preventing states from using federal funds for the administrative overhead of programs that would otherwise be ineligible for direct federal reimbursement.
Case for: Proponents would argue that including administrative costs is essential to fully enforce the prohibition and prevent federal funds from indirectly supporting these procedures. It ensures that states cannot circumvent the intent of the bill by using federal money for the infrastructure that facilitates such care.
Case against: Opponents might argue that this broadens the punitive impact on states, potentially forcing them to dismantle existing administrative structures even if they choose to fund these services entirely with state money. It could be seen as an additional layer of federal interference.
Estimated impact: This provision ensures a complete cessation of federal financial involvement in gender transition procedures for minors, including the bureaucratic support for such programs, leading to a more comprehensive federal savings and a more significant impact on state program design.
One of the exceptions to the prohibition on federal Medicaid funding is for procedures or treatments to correct for "infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in subparagraph (A), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress."
Section 2(b), adding new subsection (kk)(B)(III) to Section 1905 of the Social Security Act
Why it matters:This phrasing is likely intended to narrow the scope of permissible exceptions, ensuring that the bill's primary intent to prohibit gender transition procedures for minors is maintained, even when medical necessity is invoked. It aims to prevent the use of mental health justifications for procedures otherwise prohibited.
Case for: Proponents would argue that this clause is crucial to prevent the 'mental distress' associated with gender dysphoria from being used as a loophole to fund gender transition procedures for minors. They believe it reinforces the idea that the bill is focused on physical interventions rather than mental health treatment.
Case against: Opponents would argue that this exclusion is highly problematic because gender dysphoria is a recognized medical condition with significant mental health components, and gender-affirming care is often considered medically necessary precisely because it alleviates severe mental distress. They contend that this clause effectively denies care for a core aspect of the condition.
Estimated impact: This clause significantly restricts the scope of the medical necessity exception, ensuring that even if a minor experiences severe mental distress related to gender dysphoria, procedures defined as 'gender transition procedures' would not be federally funded under Medicaid if the distress is the *sole* justification.