In a major legal defeat for the executive branch, a federal judge in Massachusetts has struck down a key provision of a Trump administration rule designed to strip gender-affirming medical treatments of critical protections under the Affordable Care Act.
Senior U.S. District Judge Nathaniel Gorton, an appointee of President George H.W. Bush, ruled that the Department of Health and Human Services (HHS) exceeded its legal authority when it altered federal requirements to bar insurance companies from treating certain gender-affirming procedures as “essential health benefits.” Under the framework of the ACA, services designated as essential health benefits are subject to federal out-of-pocket cost caps and qualify for federal consumer subsidies—financial protections that make care affordable for millions of policyholders.
The challenged policy was embedded within the administration’s sprawling “Marketplace Integrity and Affordability” rule, a measure finalized in 2025 under the banner of reducing federal spending and curbing improper enrollment. Scheduled to take effect in 2026, the specific provision would have allowed insurers in non-grandfathered individual and small-group plans to drop gender-affirming procedures from essential health benefit status, effectively removing the law’s financial guardrails for transgender patients seeking medically necessary care.
The court’s decision came in response to a lawsuit brought by a coalition of 20 states—co-led by state attorneys general from California, Massachusetts, and New Jersey—along with Pennsylvania Governor Josh Shapiro. State officials argued that the federal government ignored statutory procedures mandated by the ACA, improperly overriding state-level authority to determine baseline coverage while threatening to drive up out-of-pocket expenses and insurance premiums for residents.
State leadership and legal representatives celebrated the ruling as a crucial safeguard against discriminatory healthcare rollbacks.
“This victory blocks the Trump Administration’s attempt to make gender-affirming care more expensive and less accessible,” said Massachusetts Attorney General Andrea Joy Campbell following the order. “Gender-affirming care is critical to the emotional and physical well-being of transgender individuals, and the Trump Administration does not have the authority to unlawfully make this care less accessible and more expensive for patients and families.”
State officials emphasized that HHS had rewritten benefit categories without adhering to federal requirements laid out by Congress. “Last year, the Trump Administration rolled out mountains of new red tape to charge Americans more money for worse coverage, including politically motivated exclusions on gender-affirming care,” Connecticut Attorney General William Tong noted in a statement. “We sued, and we stopped them, and we’re going to keep fighting to protect access to affordable healthcare free from partisan interference.”
Other state leaders echoed the sentiment, framing the administration’s policy as an overreach into private medical choices. “This rule would have made it harder for people to get the care they need and pushed costs onto families who are already managing serious health decisions,” stated Oregon Attorney General Dan Rayfield. “Those are decisions that belong between a patient and their doctor. This court ruling shows that Trump can’t use health care laws to engage in discrimination.”
California Attorney General Rob Bonta pointed out that the decision ensures gender-affirming care will remain eligible for federal subsidies and cost caps across participating states. “Everyone deserves access to health coverage,” Bonta remarked, adding that the court’s intervention preserves core protections for patients who would otherwise face uncapped, catastrophic medical bills.
While Judge Gorton sided with the state coalition by vacating the gender-affirming care provision, he upheld four other challenged portions of the broader federal rule. Nevertheless, state officials hailed the summary judgment on essential benefits as a vital wall against administrative attempts to dismantle transgender healthcare access through regulatory adjustments.
The ruling arrives as the administration continues a broader push to curb federal funding for transgender healthcare across multiple agencies, including recent regulatory efforts to restrict Medicaid and Children’s Health Insurance Program (CHIP) reimbursements for youth care. For now, however, Judge Gorton’s order maintains the ACA’s federal cost protections for enrollees nationwide, preserving the essential health benefits structure created by federal law.
