When Republicans added a provision to their reconciliation bill last month that would prevent Medicaid funds from being used to cover gender-affirming care, they thought it was a done deal. Democrats had been struggling to communicate on transgender issues since the 2024 election, so the likelihood that they would oppose it, GOP lawmakers thought, was low.
“Deep down, they know they’ve lost the issue,” Rep. Dan Crenshaw, who led the provision in the House, told NOTUS at the time.
But Democrats in Congress — led by Rep. Sarah McBride and Sen. Tammy Baldwin, whose involvement was first reported by journalist Katelyn Burns — worked quietly for weeks with trans rights advocates to keep the Senate Democratic caucus coalesced around opposing the provision and to get the Senate parliamentarian to strip the ban from the bill.
The work was done quietly. There was “understanding” among Democrats that “making it a flashy fight would decrease the pathways for removal,” one source familiar with the behind-the-scenes efforts told NOTUS.
“It was obvious to everyone who has ever had to get harmful provisions that are unfortunately relatively popular out of a bill: A public fight is not typically the best way to succeed,” this source continued.
An AP-NORC poll from May found that most adults oppose “public health insurance programs like Medicare or Medicaid from covering gender-affirming medical treatment.”
The Congressional Equality Caucus had been tracking the Medicaid ban from the moment House Republicans first released the language on May 11, a second source familiar with the efforts to kill the provision told NOTUS. At the time, the ban solely impacted Medicaid coverage of gender-affirming care for trans minors.
House Democrats did not challenge it publicly. And by the time the reconciliation bill made it to a marathon markup in the House Energy and Commerce Committee on May 13, Democrats chose not to introduce any amendments to strike down the provision. Republicans thought Democrats were just giving up on the issue.
But the second source familiar with efforts to kill the provision told NOTUS the decision not to challenge the gender-affirming care language was more practical: Democrats didn’t have the votes to defeat the ban in the Republican-controlled committee.
“The eye was always on the prize, which was getting this out through the parliamentarian and through the Senate,” the source said. “Republicans in Energy and Commerce would never vote to just strip it.”
Then the provision changed; House GOP leaders expanded the ban to impact trans people of all ages via a manager’s amendment. Almost immediately after House Republicans first passed the bill in late May, advocates activated.
“We reached out to Sen. Merkley at the Budget Committee, as well as the Finance Committee folks, Sen. Wyden’s folks and other offices as well,” said David Stacy, vice president of government affairs for the Human Rights Campaign, a group that was also working with McBride and Baldwin.
Stacy said the group reached out to the offices “fairly quickly” to flag that the provision was in the newest version of the bill, ”so that it was on their radar screen that this was going to be an issue that the Senate was going to have to deal with.”
During the over month-long “Byrd bath” — the closed-door process in which the Senate parliamentarian, Elizabeth MacDonough, determined what provisions qualify for reconciliation — Stacy said the Human Rights Campaign was “in touch with literally every Democratic office,” fielding questions via email or phone, including whether the ban only impacted minors or both minors and adults.
Baldwin, the most senior LGBTQ+ member of Congress, played an essential role: “Whipping votes and talking to colleagues, and also talking to leadership,” JoDee Winterhof, Human Rights Campaign’s senior vice president of policy and political affairs, told NOTUS.
Senate Minority Leader Chuck Schumer’s office “was certainly engaged,” Winterhof continued. But, Winterhof said, “they obviously had a lot of irons in the fire across the weekend of things they were dealing with, so, you know, Tammy is often point in talking to leadership about these sorts of things.”
Meanwhile, during a New York Times interview with McBride that was released in mid-June, the first openly trans member of Congress said Democrats “have to negotiate with public opinion” on trans issues.
“We have to be better as elected officials in saying no, in saying: Public opinion is everything,” McBride said. “If you want us to change, you need to help foster the change in public opinion before you’re asking these elected officials to betray the fact that they are, at the end of the day, representatives who have to represent in some form or fashion the views of the people that they represent.”
The interview prompted senators to reach out individually to McBride. It showed that she “understood the challenging political dynamics on some of these issues,” the first source familiar with the behind-the-scenes efforts told NOTUS.
Those one-on-one conversations quickly turned from addressing the politics of it all to an opportunity to talk to senators about the Medicaid gender-affirming care ban in the reconciliation bill.
“I think having both Sen. Baldwin and Rep. McBride to talk to, you know, colleagues across the dome … is very important in this process,” Winterhof told NOTUS. “They both worked this very hard and had multiple conversations with members.”
Stacy said advocates communicated constantly with Wyden’s staff, who led the efforts to argue to MacDonough that the provision should be disqualified. (According to the Williams Institute, over 185,000 trans adults use Medicaid as their primary source of health insurance.)
The best bet for Democrats, the second source familiar said, was to convince the parliamentarian that the budgetary changes the provision would make — the Congressional Budget Office had determined it would save about $2.5 billion over the next 10 years — were “merely incidental” (meaning that the specific clause has mostly a policy-making effect rather than a budgetary one).
“That was always, I think, the strongest argument against it,” the source said. “This isn’t really about saving money. It’s ultimately about, they want to strip health care away from trans people.”
On June 26, Sen. Jeff Merkley announced that MacDonough had rejected the Medicaid ban, meaning the provision needed 60 votes to pass. Guidance provided to Senate offices from the parliamentarian is usually extremely brief, with little details about the underlying reasons behind the judgment, according to a Senate aide familiar with the process.
Two days later, on a Saturday, Senate Republicans released an updated version of the bill. But despite the parliamentarian’s decision, the Medicaid ban remained in the text, seemingly to challenge Democrats to vote on a topic conservatives claim was their winning issue in 2024.
But Democrats intensified their private push to ensure the caucus in the upper chamber would stay unified in opposing the bill — something they, and their allies, expected they’d have to do.
“You didn’t see us taking some giant victory lap because we knew full well that the odds of this coming back up in some manner were very significant, right?” Wintehof said. “That was strategic on our part.”
Rep. Mark Takano, chair of the Equality Caucus, told NOTUS he directed his 11 co-chairs to contact their senators to ensure “there was sufficient commitment to sustain the point of order.”
“We figured this would show that we were paying attention,” Takano said.
When the congressman reached out to the members Saturday evening, McBride — one of the caucus’ co-chairs — informed him she was already in touch with senators.
“I wanted to make sure that I was doing no harm by making sure that we were coordinated,” Takano said. The weekend, he added, was “a long game” of texts, calls and updates of “piecing together” what he, McBride, other members and allies were hearing from Democratic senators.
In a statement to NOTUS, a spokesperson for McBride said the congresswoman “is grateful for the friendship and solidarity of her Democratic colleagues across Congress and their collective commitment to protecting health care coverage for all Americans.”
The Human Rights Campaign team, for their part, had “a weekend of calls,” Winterhof said. “The team put in a lot of hours on this, and we also activated membership and had calls going in on the overall bill, as well as, you know, this provision.”
The Senate’s record-breaking, 27-hour vote-a-rama started on Monday morning. The plan was for Baldwin to raise a point of order on the provision once the Senate started votes on the bill itself, four sources told NOTUS. However, when Tuesday morning rolled around, less than an hour before the Senate narrowly passed the bill, GOP leaders dropped the Medicaid ban on gender-affirming care.
Senate Republicans ultimately “honored” the parliamentarian’s ruling and “removed the provision,” a Baldwin spokesperson said in a statement to NOTUS.
“No point of order was brought up by Democrats to strike the provision. Democrats, including my boss, of course, were not involved in writing this bill whatsoever,” the statement said.
The offices of Senate Majority Leader John Thune, the Senate Budget Committee and the Senate Finance Committee did not respond to NOTUS’ requests for comment as to why the language was struck at the last minute. House Republicans who were angry about the change, though, theorized that senators wanted to finish the legislation and send it to the House before President Donald Trump’s July 4 deadline — and a point of order would have only slowed them down.
“The Senate acted out of fear,” Crenshaw said in a statement on X. “Instead of daring the Democrats to raise a point of order thereby SUPPORTING taxpayer funding of transgender therapies, Senate Republicans caved.”
“Senators chose the easy path instead of fighting it. Disgraceful,” he continued.
In the hours that followed, House Republicans publicly denounced the exclusion of the provision, but nothing changed. Rep. Marjorie Taylor Greene offered an amendment to add the restriction back, which failed, and the House Freedom Caucus suggested its members also wanted to add the ban back.
That never happened. The House passed the Senate’s version of the bill — no Medicaid ban on gender-affirming care in sight.
Had it been added, however, the bill would have been sent back to the Senate, where the provision would have been subject to a point of order. Democrats believe that, in any case, they would have defeated the ban.
“Working behind the scenes,” Takano said, “I think made a difference.”