House Republicans who waged fierce political battles over Obamacare and abortion after that have found a new focus as the lead-up to the 2024 elections: gender-affirming care for transgender Americans.

They’ve added riders on seven of the 12 House fiscal 2024 appropriations bills that would put restrictions on gender-affirming care, which can be anything from hormone therapy to surgical care to insurance coverage of either.

The fight has extended beyond spending bills into policy measures as well: They’ve held up traditionally bipartisan programs to pay for pediatrician training over hospitals’ decisions to provide such care. Another bill would create a global gag rule for gender-affirming care similar to the Mexico City policy for abortion care.

And they’ve threaded their concerns over the issue into the debate over the annual defense authorization bill — a fight that could threaten the passage of that bill.

“The volume here is just orders of magnitude different than anything we’ve ever seen,” David Stacy, the vice president of government affairs at the LGBTQ+ advocacy group Human Rights Campaign, said.

Most of the bills have little chance of passing the Democratic-majority Senate or escaping the veto of Democratic President Joe Biden.

But that’s not the point for conservative culture warriors who want to lay down an ideological marker as the 2024 elections approach.

“It’s important for Republicans to establish a pattern about their perspective,” said Jay Richards, a senior research fellow at the conservative Heritage Foundation, calling the organizing efforts a “preparation for what’s to come” in the 2024 election.

Appropriations riders

This is the first year that Republicans have tacked on amendments to ban gender-affirming care to appropriations bills, according to both the Human Rights Campaign and an analysis of past bills. The riders include:

• The Labor-HHS-Education, Military Construction-VA and Defense bills would prohibit federal funds from going toward any gender-affirming care treatment, including surgical procedures or hormone therapies.

• The Commerce-Justice-Science bill would prohibit federal funds from being used for a sex-altering surgical procedure in either a federally-owned or a private facility being used by the federal government.

• The Financial Services bill would prohibit the Federal Employees Health Benefits program from covering the cost of surgical procedures, puberty blockers or hormone therapy for the purpose of gender-affirming care.

• The Homeland Security spending bill would prevent any funds from being used to administer hormone therapy, medication related to gender-affirming care or gender-affirming surgery for people in custody of Immigration and Customs Enforcement.

• The State-Foreign Operations bill would prohibit federal funds from going to fund any domestic or international nongovernmental organization that offers counseling regarding sex change surgeries, offers gender-affirming care or “otherwise promotes transgenderism.”

Other policy priorities

House Republicans are also looking to block gender-affirming care for veterans and their families on TRICARE through the annual defense authorization bill. The House-passed version of the bill includes policies that would bar TRICARE from providing gender-affirming care to all beneficiaries. The Senate version of the bill includes no such similar provisions.

Currently TRICARE covers nonsurgical treatments for gender dysphoria, such as hormone therapy, but is explicitly prohibited from covering gender-affirming surgical care, except when treating intersex patients or chromosomal abnormalities.

The Children’s Hospitals Graduate Medical Education program, which pays for residencies and fellowships for medical students training to be pediatricians, is typically a noncontroversial, highly bipartisan health care reauthorization that sails out of the House Energy and Commerce Committee.

But this year, the bill may be held up by a fight over a provision related to gender-affirming care for minors.

Rep. Daniel Crenshaw, R-Texas, introduced a version of the legislation that would bar any federal funds to hospitals that provide gender-affirming care, including hormone therapy and 19 specific procedures for transgender youth. The House Energy and Commerce Committee approved the bill along party lines in July.

On the Senate side, Sen. Bob Casey, D-Pa., is pushing for a reauthorization without such a provision.

But Crenshaw isn’t letting up in the House.

“This is the issue of our time. This is the hill we’re going to die on,” Crenshaw said of gender-affirming care during a summer legislative hearing on the bill.

This is the first year transgender health care has become a marquee issue for Republicans on Capitol Hill and it comes after anti-trans legislation has been intensifying in statehouses across the nation.

In 2021, state legislatures proposed more than 120 bills negatively targeting transgender people, according to data from the National Center for Transgender Equality.

That spiked to more than 200 anti-trans bills introduced in 2022 and more than 450 in 2023. Gender-affirming care is currently banned in 22 states, according to the Human Rights Campaign.

A big part of LGBT advocacy groups’ work these days revolves around meetings with lawmakers and talking to them about trans people in their districts.

Rodrigo Heng-Lehtinen, the executive director of the National Center for Transgender Equality has spent the last few years climbing the Hill to meet behind closed doors with what he describes as more moderate Republicans in the House.

Heng-Lehtinen has a secret weapon with him: former GOP House member Ileana Ros-Lehtinen of Florida is his mother. Since the former Energy and Commerce Committee member retired in 2019, she’s worked as a lobbyist. Mother and son team up to advocate to her former Republican colleagues about transgender rights.

Heng-Lehtinen expects GOP vitriol to intensify in the next year after the election of Speaker Mike Johnson, R-La., who has described the increase in gender-affirming care as “radical and misguided.”

Last year, Johnson introduced legislation modeled after Florida’s “don’t say gay” bill that would have prohibited discussion of sexual orientation and gender identity in any institution that receives federal funds. In the House Judiciary Committee, he’s been a leading Republican championing anti-trans policies.

“This so-called gender affirming care is anything but affirming and caring,” Johnson said during a House Judiciary Committee hearing he hosted earlier this year titled “The Dangers and Due Process Violations of ‘Gender-Affirming Care’ for Children.”

Johnson’s firmly held beliefs have inspired Democrats and activists to vow to keep his policies in the House. Last week, citing Johnson’s record, Senate Democrats pledged to block any legislation that would block access to abortion or gender-affirming care.

The League of Women Voters sent a letter to Democratic leadership just before the initial Sept. 30 government funding deadline, saying they were “appalled” to see restrictions on gender-affirming care in the funding bills and urging them to vote against these bills.

But some advocates worry these promises can only go so far when, at the end of the day, lawmakers feel the pressure of a government shutdown looming after Nov. 17.