Who Decides What’s Best for Your Child? Not Washington.

Part 1 of 3

The federal government is attempting something that, until now, would have been unthinkable: inserting itself into private medical decisions made by children, their families, and their doctors — not because a treatment is dangerous, not because families are being harmed, but because of politics.

The proposed rule RIN 0938-AV87 would prohibit Medicare and Medicaid participating hospitals from providing gender-affirming medical care to transgender and gender-diverse youth. Public comments on this rule are now closed, but I want to share my concerns and ensure that accurate information about this topic remains available. As a board-certified psychologist who has spent years working with these young people and their families, I find this proposal deeply alarming — not only for what it would do to vulnerable kids, but for what it would do to American medicine.

Families Know Their Children. Politicians Do Not.

Healthcare decisions for children have always been—and should remain—the province of parents working with qualified medical professionals. That’s not a radical position. It’s the foundation of American pediatric medicine.

The parents I work with don’t arrive at these decisions lightly. They consult multiple specialists. They research the literature. Many pray over the decision according to their faith traditions. They sit with their child through comprehensive psychological evaluations that can span months. Conservative parents, religious parents, parents from every walk of life—all of them exercising the most fundamental responsibility a parent has: determining what is best for their child’s health and wellbeing.

This proposed rule erases all of that. It substitutes a blanket federal prohibition for the individualized judgment of parents and physicians who actually know the child in question. A bureaucrat in Washington, D.C. who has never met your child—who has no knowledge of your child’s medical history, psychological state, or circumstances—would now effectively make that medical decision for you.

The constitutional foundation for parental authority in medical decisions is well-established. The Supreme Court has long interpreted the Fourteenth Amendment’s Due Process Clause to protect parental rights as among the most fundamental liberty interests—including the right to make medical decisions on a child’s behalf . This is not a fringe legal position. It reflects over a century of constitutional jurisprudence holding that parents, not the state, are presumed to act in their child’s best interest.

A Dangerous Precedent

“Doctor examining baby boy with otoscope” by EU-Ukraine Cooperation, CC BY-SA 2.0

The proposed rule attempts to sidestep Section 1801 of the Social Security Act, which explicitly prohibits federal supervision or control over the practice of medicine. It does so by claiming that gender-affirming care isn’t really “medical practice.” This is semantic sleight of hand. The rule prohibits medical professionals from providing medical treatments to patients who need them. That is, by any honest definition, controlling medical practice.

If this rule stands, it establishes that the federal government can override medical consensus and ban treatments based on ideological preferences rather than evidence. Think carefully about where that logic leads:

• A future administration could restrict reproductive healthcare on similar grounds.
• End-of-life pain management could be targeted.
• Parents’ ability to make vaccination decisions could be removed.
• Off-label medication use in children—extremely common in pediatric medicine—would be vulnerable.

Once the principle is established that federal policymakers can prohibit evidence-based treatments because they’ve decided the evidence is “insufficient,” there is no principled limit. Different administrations could ban different treatments based on whoever holds power at a given moment. That is not medicine. That is politics wearing a white coat.

The Wealth Gap This Rule Creates

There is a dimension of this proposal that has received too little attention: it is, at its core, a rule that takes a right away from poor families while leaving it intact for wealthy ones.

Medicare and Medicaid account for more than 60% of all care provided by hospitals, meaning the vast majority of hospitals cannot practically opt out of participation . Banning gender-affirming care at these institutions doesn’t eliminate access—it eliminates access for families who can’t pay cash. Wealthy families could theoretically seek care at the small minority of facilities that don’t participate in these programs. Everyone else is simply out of luck.

For the nearly half of American children covered by Medicaid or CHIP—approximately 40 million children as of 2023, representing between 39% and 49% of all children depending on the year and data source —there is no “alternative.” There is no boutique cash-pay hospital they can drive to. There is no ability to finance a $30,000–50,000 procedure or absorb $200–500 in monthly medication costs. In my clinical practice, I have worked with families across the full economic spectrum, and the reality is stark: a family earning minimum wage cannot simply choose a different hospital.

This disparity compounds existing inequities. Children of color are disproportionately represented among Medicaid enrollees—Medicaid and CHIP cover more than half of Hispanic, Black, and American Indian/Alaska Native children, compared to 27% of White children . Single-parent households are more likely to be low-income. Rural families often have no healthcare options other than their local Medicare/Medicaid-participating hospital. The proposed rule doesn’t just deny care—it denies care specifically to the most vulnerable children in America.

The disparities this rule would create are not hypothetical. Research already documents widespread racial and ethnic inequities in the quality of pediatric care in the United States—inequities that persist even after controlling for insurance status . A rule that further concentrates healthcare access among wealthy families will only deepen those divides.

CMS has repeatedly stated its commitment to health equity. This rule is the opposite of that commitment.

What This Is Really About

The decision about whether gender-affirming medical care is appropriate for a given child should be made by that child’s family and their chosen medical providers—people who know the child, have reviewed their history, and have weighed the individual risks and benefits. Research examining transgender adolescents’ and their families’ healthcare experiences confirms that families deeply value these trusted relationships with their providers and want to make decisions collaboratively . Separately, a comprehensive review in the Annual Review of Clinical Psychology documents that transgender and gender diverse youth experience significantly elevated psychological distress relative to their peers—driven primarily by minority stress, stigma, and lack of support—and that family support and gender-affirming care are among the most important protective factors . A federal policy that removes families’ ability to access recommended care directly undermines those protective factors.

The federal government has no such knowledge. It has no such relationship. And it has no business making this call.

Next in this series: What the medical and scientific evidence actually shows about gender-affirming care for youth.

References