Trump administration caves after avalanche of opposition to anti-trans hospital rule

A flood of public opposition helped stop one of the Trump administration’s most extreme attempts to force hospitals nationwide to abandon gender-affirming care for transgender young people, offering a rare and instructive victory against a federal government that has otherwise moved aggressively to dismantle trans rights.

The Department of Health and Human Services has abandoned a proposed rule that would have threatened hospitals with the loss of all Medicare and Medicaid funding if they continued to provide transition-related care to minors, NPR was first to report on Monday. The proposal, issued in December, never took effect.

Its collapse followed more than 30,000 public comments submitted to the Centers for Medicare and Medicaid Services. Nearly 20,000 came from Human Rights Campaign members and supporters, according to the organization. Equality California said major medical groups, including the American Medical Association, the American Academy of Pediatrics, and the Children’s Hospital Association, also urged the administration to withdraw the rule.

The administration has not publicly credited the comments for its reversal. But former federal health officials and administrative law experts told The Advocate that the public record created through the comment process can expose legal weaknesses, force agencies to confront evidence they would rather ignore, and make a rule more difficult to defend in court.

“It’s pretty rare for an agency to go to all the trouble of issuing a notice of proposed rulemaking and then decide they’re just not going to do anything,” Sam Bagenstos, a University of Michigan law professor who served as general counsel at both the Department of Health and Human Services and the White House Office of Management and Budget during the Biden administration, told The Advocate in an interview Tuesday.

Agencies often revise a proposal after reviewing public feedback, he said. Walking away entirely is less common.

“Sometimes the comments come in, and it’s just overwhelmingly clear that the rule that they want to propose is indefensible,” Bagenstos said. “And so an agency says, ‘We’re just not going to go forward with this and waste everybody’s time, including waste our own time losing lawsuits.’”

Related: Judge blocks Trump DOJ’s latest effort to obtain medical records of transgender minors

More than an online petition

The abandoned rule would have imposed a new condition on hospitals participating in Medicare and Medicaid. Hospitals providing puberty blockers, hormone therapy, or certain surgeries to patients younger than 18 for gender transition could have been expelled from the federal insurance programs.

The threat extended far beyond reimbursement for transgender care. A hospital found in violation could have risked Medicare and Medicaid payments across its operations, jeopardizing care for older adults, disabled people, low-income patients, and children.

Conditions of participation rules have traditionally been used to ensure that hospitals meet health and safety standards. The proposed rule would have transformed that authority into a weapon against a specific category of care and the patients who rely on it.

That made the public comment period more than a symbolic outlet for anger.

Under the Administrative Procedure Act, notice-and-comment rulemaking generally applies when federal executive departments and independent agencies — including HHS, the Justice and Education departments, the Environmental Protection Agency, the Federal Trade Commission and others — propose substantive regulations under authority granted by Congress. Agencies typically publish a notice of proposed rulemaking in the Federal Register, explain the proposal and its legal basis, accept comments, consider significant factual, legal and policy objections, and then either withdraw the proposal or publish a final rule explaining their decisions and stating when it takes effect. Not every federal action follows that process. Executive orders, enforcement decisions, internal directives, and many guidance documents are generally excluded, and the law contains exceptions for certain interpretive, procedural, military, foreign affairs, and emergency actions.

Federal agencies must consider significant comments that raise legal, factual, or policy objections.

“If there’s a substantive comment, if there’s a comment that highlights the effects that a rule is going to have on some particular population or that highlights a legal argument that might affect the validity of the rule, the agency has an obligation to respond to that,” Bagenstos said.

“It’s not just a check-the-box exercise,” he added. “They have to actually give some reasoned elaboration of why they’re continuing to move ahead, notwithstanding the comment, or they have to make changes that are responsive to the comments.”

When agencies fail to do that work, courts can vacate their regulations.

That is why a detailed comment describing how a policy would disrupt a hospital, a state Medicaid program, a family’s care, or a patient’s life carries more legal weight than a form letter expressing generalized opposition. The comment becomes part of the administrative record that the government must answer and that judges can later review.

Bagenstos said the strongest comments explain the specific consequences of a proposed policy, particularly when people and institutions have relied on existing rules while making important decisions.

“The crucial thing is being specific about the effects of a policy change on you and on communities that you’re a part of,” he said, “because those are the kinds of specifics that the Trump administration is going to have to respond to, or it’s going to be at risk of losing in court.”

Related: Republicans rage after Trump appears to soften stance on trans care

‘An avalanche of outrage’

HRC President Kelley Robinson described the administration’s retreat as proof that mass public engagement can still produce results.

“It takes an avalanche of outrage to stop this administration from doing harm to innocent people, and together, we the people delivered to protect transgender youth across the country,” Robinson said in a statement.

“Together, we have stopped Donald Trump and RFK Jr., this time, from imposing their malignant will in every doctor’s office and home when it comes to what is the right and appropriate treatment for trans people — decisions that should be left up to medical professionals, the patients themselves, and their loved ones,” she said.

Robinson cautioned that the reversal does not restore access in states where gender-affirming care remains prohibited or undo the damage caused by hospitals that ended treatment in anticipation of federal punishment.

“Make no mistake, this is a reprieve, not a victory, and only for some,” she said. “There are still many states that ban life-saving health care for political reasons, and too many medical facilities complying in advance that weren’t required to. But this is a reminder of our movement’s power to fight back, speak up, and win.”

Equality California Executive Director Tony Hoang likewise called the decision a “hard-fought victory” produced by sustained advocacy and growing resistance to the administration’s agenda.

“Since returning to office in January 2025, Donald Trump and his administration have relentlessly attacked the rights and freedoms of countless Americans, with transgender youth among their most frequent targets,” Hoang said in a statement.

He said the abandoned proposal represented a misuse of federal rules intended to ensure that medical providers meet basic health and safety standards.

Related: Judge blocks Trump DOJ from seizing trans youths’ medical records from NYC hospitals

A rare retreat

Adrian Shanker, who served in the Biden administration as deputy assistant secretary for health policy and senior adviser on LGBTQ+ health equity at HHS, said the abandoned proposal represented a profound distortion of programs intended to expand access to medical care.

“Policy around Medicaid and CHIP is supposed to be about how do we expand access to care? How do we ensure that the American people have the care that they need?” Shanker said. “Not, how do we drive political wedges and hot-button issues to try to build barriers to care?”

The decision not to finalize the rule, he said, showed that public engagement is powerful, even under an administration that has frequently disregarded legal norms and institutional restraints.

“Public comments do matter in the regulatory process,” Shanker said. “This should be a reminder for people who care deeply about this issue that proposed rules are only proposed rules. And until they’re finalized, there is a process to let your voice be heard.”

He said the tens of thousands of comments “made a huge difference in ensuring that the rule would not be finalized.”

The administration continues to pursue a separate proposed rule that would prohibit Medicaid from covering transition-related care for people younger than 18 and the Children’s Health Insurance Program from covering it for those younger than 19.

That measure targets payment for the care itself. The abandoned rule would have gone further, threatening a hospital’s participation in Medicare and Medicaid altogether.

The administration has also targeted providers through investigations, grant cancellations, record demands, grand jury subpoenas, and other regulatory actions. Shanker described the campaign as a layered strategy designed to make the provision of transgender health care legally, financially, and politically untenable.

“The Trump administration has put layer upon layer upon layer of their attacks against the health and well-being of transgender Americans,” he said.

Related: Trump admin eliminates health care programs for LGBTQ+ veterans

Hospitals surrendered before they had to

Some hospitals suspended or ended gender-affirming care for young patients in response to the administration’s threats, even though the rule was only a proposal and carried no force of law.

Shanker called that advance compliance a major victory for the administration and a profound loss for transgender patients, their families, and the clinicians who continued to provide care under extraordinary political pressure.

“There was significant damage done by the compliance in advance with an unfinalized rule,” he said.

Hospitals faced a deliberate atmosphere of uncertainty. The administration paired the funding proposal with Justice Department pressure, federal investigations, and efforts across multiple agencies to characterize gender-affirming care as dangerous, fraudulent, or unlawful.

Shanker said providers were wrong to discontinue care preemptively, even if their fear was understandable.

“I think their decisions to comply in advance are wrong,” he said. “I understand where it came from.”

He urged advocates to pressure hospitals that stopped treatment to resume it, particularly in states where gender-affirming care remains legal, and Medicaid programs can continue covering it.

A road map for resistance

The decision offers no evidence that the Trump administration has moderated its broader hostility toward transgender people.

Bagenstos called the move a “tactical retreat,” not a change in direction.

“This administration has made clear, including in recent weeks, that they are committed to a very oppressive set of policies involving trans people,” he said. “On this rule at this moment, they’re pulling back. That doesn’t mean they’re changing their overall policy.”

But tactical retreats matter. Each abandoned proposal delays harm. Each successful court challenge consumes government time and resources. Each substantive public comment creates another fact or legal objection the administration must confront before its policies can survive judicial review.

Bagenstos described the work as “trench warfare in administrative law,” filing comments, forcing agencies to respond, and challenging final rules when the administration cuts corners or ignores the record.

“What we’ve seen in this administration is that the only thing that has slowed them down, and it’s been imperfect, but it has worked to some extent,” he said.

Every challenge forces the administration to spend more time defending its actions and less time implementing them, he said.

“People really should be looking for these proposed rules,” Bagenstos added. “They should file comments that tell their stories, that provide facts to the agency that the Trump administration is going to have to take account of, or else it will be at risk of losing in court.”