TrustWorks On Call: Pride Flagged

Behind the Headlines

Unpacking the forces driving healthcare's biggest stories.

1. SCOTUS upholds ban on gender-affirming care for minors.

Last Wednesday, the Supreme Court ruled in favor of a Tennessee law that prohibited providers from prescribing transgender patients under the age of 18 with puberty blockers and hormone therapy.
Plaintiffs in the case, United States v. Skrmetti, argued that the law discriminated based on sex and violated the equal protections clause of the 14th Amendment.
Chief Justice John Roberts, writing for a 6-3 majority, instead found that the law “prohibits healthcare providers from administering puberty blockers or hormones to any minor to treat gender dysphoria, gender identity disorder, or gender incongruence, regardless of the minor’s sex.” (Italics added for emphasis.)
This ruling establishes legal backing for the 26 states that have passed laws banning gender-affirming care for minors since 2021, as well as a series of executive orders signed by President Trump targeting trans people, especially trans youth.

TrustWorks Take: As the legal critiques of this ruling are well covered in Justice Sotomayer’s dissent, our healthcare newsletter is more suited to evaluating Roberts' claim of an “ongoing debate among medical experts” that led Tennessee legislators to ban puberty blockers and hormone treatments for trans youth. Across all reputable reviews of the literature, medical experts are united in their conclusion that we need more “rigorous longitudinal and mixed methods research” to better understand the impacts of certain treatments for gender dysphoria in youth. However, higher-quality studies are urgently needed specifically because the initial, imperfect studies have found “significant inverse associations between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment.” Given estimates that 40 percent of trans people have attempted suicide and over 80 percent have considered the act, the potential benefits of puberty blockers for trans youth are immense. In comparison, the potential physical risks, such as altering the body’s growth function, and subjective harms, such as regretting one’s gender transition, are relatively minor and rare. For example, in a study of 220 youth who received either puberty blockers or hormone therapy to treat gender dysphoria, only nine kids expressed any regret with their treatment decisions, four of whom continued treatment anyway. Science benefits from debate and evidence-based disagreement, but in the case of youth treatment of gender dysphoria, the body of scientific evidence is on one side and the current political winds are on the other.

2. FDA approves Gilead’s HIV prevention shot.

Gilead Sciences announced last Wednesday that the Food and Drug Administration (FDA) has approved Yeztugo, the first twice-yearly treatment option for HIV pre-exposure prophylaxis (PrEP), after trial data showed over 99.9 percent of participants remained HIV negative.
Each Yeztugo injection confers six months of HIV protection, which is expected to improve treatment access and adherence compared to the daily oral pills or monthly shots already on the market.
As of 2022, only 36 percent of people who could benefit from PrEP had been prescribed it, up from 23 percent in 2019.

TrustWorks Take: Thanks to advancements in treatment and prevention, as well as reduced stigma around the disease and the behaviors associated with contracting it, the incidence and mortality of HIV/AIDS in the US have steadily and significantly declined since their peak in the 1990s. Still, almost 38K Americans, most commonly gay and bisexual men, contracted HIV in 2022. Black and Latino people are disproportionately likely to contract HIV in part because they receive PrEP prescriptions at drastically lower rates: among those who would benefit from a PrEP prescription, only 13 percent of Black people and 25 percent of Latino people have been prescribed PrEP, as compared to 94 percent of white people. By replacing regular medical visits with a twice-annual shot, Gilead’s new medicine could greatly improve access for these underserved populations and anyone who lacks consistent access to a healthcare provider—not just in America, but across the world too. However, other barriers like cost, systemic bias, and social stigma remain in the way of medical breakthroughs like Yeztugo achieving their maximal societal benefit.

3. CMS shortens ACA signup periods, tightens eligibility and coverage rules.

On Friday, the Centers for Medicare & Medicaid Services (CMS) finalized a rule that shortens the open enrollment period for Affordable Care Act (ACA) exchange plans by about one month, cancels a special enrollment period for low-income people, and adds new income verification requirements, among other changes.
CMS projected that the rule will lower individual marketplace premiums by about five percent and reduce federal spending by up to $12B in 2026; ACA enrollment could shrink by 750K to 1.8M next year.
The Trump administration justified the need for stricter enrollment standards by pointing to examples of improper enrollment and fraudulent behavior by insurance agents and brokers.
The rule also removes gender-affirming care from the list of essential benefits insurers must cover under the ACA and denies Deferred Action for Childhood Arrival recipients, also known as Dreamers, from enrolling in marketplace plans.

TrustWorks Take: There’s an inherent tradeoff between tolerance for fraud and ease of access in benefit design, but, in light of its other moves to restrict government-sponsored health coverage, the Trump administration seems unbothered by (or else, interested in) reducing access to ACA plans. ACA marketplace fraud, which the Biden administration moved to regulate just before leaving office, is a convenient excuse to reduce the generosity of federal subsidies for ACA plans as well. The drastic spike in the uninsured population generated by this administration’s regulatory and legislative policymaking will not only be disastrous for patients relying on this coverage, but also for their providers, who will face lower volumes and higher rates of uncompensated care that further strain their margins.

Beyond the Whiteboard

Visualizing key trends from the healthcare industry

Federal Judge Reverses Some “Discriminatory” Grant Cuts
Amid the whirlwind of policies the Trump administration has adopted in the name of government efficiency, from laying off federal workers to championing legislation that slashes Medicaid benefits, the defunding of scientific research has at times flown under the radar. Thankfully, the private efforts of a team of researchers behind Grant Watch have been tracking the impact. Since February, the administration has terminated about 2,500 grants issued by the National Institutes of Health, amounting to over $3B of lost funding. For context, publicly reported biomedical grant funding totaled $37B globally in 2022, and the NIH was responsible for over 80 percent of that figure. As reported by the New York Times and ProPublica, most of these grants are being cancelled for arbitrary and capricious reasons, such as the detection of flagged words in their proposals. Some of these words and phrases range have partisan or political connotations (e.g. LGBTQ, sex assigned at birth, health disparity), while others seem completely anodyne—“bias” has emerged as a particularly egregious example of a flagged word frequently used in science outside of any political context. The impact of these cancelled grants, let alone the future projects that will not receive funding, could set the world of science and biomedical research back for years, if not decades.

Then, last week’s news offered up a bright spot. A district court judge (appointed by Reagan) ruled that the termination of NIH contracts was “void and illegal” and ordered the reinstatement of grants identified by the plaintiffs. Furthermore, he went on to say, “This represents racial discrimination, and discrimination against America’s LGBTQ community … I would be blind not to call it out. My duty is to call it out.” As with all judicial actions short of the Supreme Court, questions of scope, appeal, and enforcement remain, but it’s heartening to see a federal judge stand up for scientists and marginalized communities so strongly.

Dialing In

Sharing insights from our work with clients

When is LGBTQ+ Healthcare Just Healthcare?
During a Pride Month some years ago, well before the launch of this newsletter, I attended a panel that challenged and changed the way I think about LGBTQ+ healthcare. The panel featured a few “members of the coalition” (as they put it) who worked in care delivery and were asked to speak on their experiences as both patients and providers.

In particular, I recall the answers to an open-ended question the moderator asked along the lines of, “What do you see as the most pressing failures of our healthcare system toward LGBTQ people?” Someone spoke convincingly of stigma, bias, and inadequate medical training; another talked about the significant challenges faced by transgender people, especially as it intersects with their other identities; but the answer that I’ll never forget came from a lesbian nurse who said the main problems faced by people like her in the US healthcare system stemmed from payment, coverage, and affordability. “LGBTQ healthcare isn’t really a thing. It’s many things for many people, but what pretty much every queer person has in common is needing more care, a lot of it specialized, and that gets expensive quickly.” She went on to point out how LGBTQ+ people not only report greater rates of poor physical and mental health, but also financial health. While she was happy to have been invited to this panel, she also acknowledged that all the speakers and audience members were healthcare workers, which came with a certain level of financial stability and knowledge of how to access the system that she often didn’t see in her LGBTQ+ patients.

This panel left me thinking about how most of the time, LGBTQ+ people have the same type of problems with healthcare as everyone else—access, affordability, and equity—only to a greater degree. It’s not a niche concern to be dismissed, but rather a mirror for our healthcare system more broadly. If we can build a system that works for LGBTQ+ patients, then we might just be able to build a system that works for everyone. When is LGBTQ+ healthcare just healthcare? When we realize that making it better for the most vulnerable is how we make it better for us all.

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Pride Flagged