When Mars Wright saw that Donald Trump was re-elected president, the 29-year-old artist and streetwear designer from Los Angeles was relieved that he had already undergone surgery for his gender transition.

Wright, a transgender man, chronicled his medical journey online, flexing and dancing to show how his body transformed after a masculinization procedure he nicknamed the “Dorito chip” for the way it altered form. His surgery was covered by an LA Care plan he obtained through Covered California, the marketplace established under the Affordable Care Act for Californians to buy insurance.

“I’m privileged to be here,” Wright said of living in California. “And I’m thinking about how people are going to have to come here … to be able to have a medical transition.”

California leaders have sought to protect access to such procedures for transgender people. State-licensed health plans must provide transgender enrollees with gender-affirming medical care. Doctors who provide such care in California are legally protected from laws that criminalize it in other states.

But experts and advocates say that even in California, access to gender-affirming care could be undermined by federal action as Trump takes office for a second term, promising to stop “left-wing gender insanity” and calling gender transition for minors a form of child abuse. State lawmakers have vowed to push back against efforts to block gender-affirming care, which could spark future court battles.

“I’m not going to sit here and say that California can roll back any vile federal attack on trans people,” said state Sen. Scott Wiener (D-San Francisco), who has advocated for protections for transgender patients and their doctors. “But we will do everything in our power to stay in favor of the community.”

President-elect Trump has vowed to press Congress to block the use of federal funds for sex-affirmation care, including surgery, a position also reflected in Republican party platform. It remains to be seen exactly how a ban would be enforced, but experts said the Trump administration could model it after the Hyde Amendment, which for decades widely banned using federal funds for abortion.

Eliminating federal funding would have major effects because “almost every corner of the health care system has some element of federal funding in it,” said Kellan E. Baker, executive director of the Whitman-Walker Institute, which does health research and advocacy. health. issues for LGBTQ people. Its effects “would fall most significantly on those who are least positioned to afford the health care they need.”

Among those affected, he said, are transgender people who rely on public programs like Medicaid. However, experts said that because Medicaid is jointly funded by states and the federal government, California leaders could choose to use state funds to pay for gender-affirming care.

“California has shown a penchant for funding things that go beyond what Medicaid will do nationally,” such as covering low-income Californians regardless of immigration status, said John Baackes, executive director of LA Care, a plan to health that serves more than 2 people. millions of people in LA County. “The state could say, ‘OK, we’ll fund it.’

Mars Wright sits in a small studio apartment in his apartment with his elderly dog ​​Lucy.

(Gina Ferazzi/Los Angeles Times)

Trump is also expected seek changes to Medicaid that would reduce federal spending, which could strain California financially if it wants to continue other existing programs under Medi-Cal, the states’ Medicaid program. But advocates said transgender people make up a small portion of the population — estimated at 0.6% of US adolescents and adults in one analysis—bearing the costs of gender-affirming care would not be a major expense.

Experts said states have a lot of leeway over their spending, but Trump tried to use Medicaid to pressure California on his policies. Near the end of its first term, the Trump administration threatened to detain some Medicaid funding in California because the state required insurers to cover abortion care.

That threat eventually died down, but it could hint at how his administration might try to pressure California. A representative for Trump did not respond to an email seeking comment on the possibility.

At clinics run by the Los Angeles LGBT Center, anxious patients ask, “Should I get hormones for a year now? Should I have all the surgeries I’ve ever wanted to have?” said Dr. Kaiyti Duffy, its chief medical officer. She tried to assure them that “as long as we can provide these services, we will.”

Trump could also pursue broader restrictions that not only bar federal dollars from being used for gender-affirming care, but also bar providers of such care from getting federal funding.

Some of its proposals specifically target gender-affirming care for young people, which has been a focal point for groups that fight it harms children who do not understand the implications of such treatment. Greg Burt, vice president of the California Family Council, called it “the biggest lie this state has ever perpetrated on our young people, to tell children it’s possible to be born in the wrong body.”

American Academy of Pediatrics recommend that transgender youth have access to comprehensive gender-affirming care.

In the Central Valley, one mother said puberty blockers were a “pause button” that eased the despair for her transgender child, now 14, and gave the family time to figure out what she needed. The military family, which relies on the federally funded Tricare insurance for service members, consulted with doctors and eventually went ahead with testosterone hormone treatment.

“At every stage of his medical care, he became more and more himself,” said the mother, who asked not to be identified to protect her teenager’s privacy. “He went from being quiet and silent to active, alive and thriving.”

If her child doesn’t get such care in California, she said, they are making plans to leave the country.

Trump has called for banning gender-affirming youth care in every state, calling it mutilation. During the campaign, Trump said he would seek to drop any health care provider who “engages in the chemical or physical mutilation of young minors” from Medicaid and Medicare.

The Medicare and Medicaid programs are “the biggest lever the federal government has because hospitals get so much money” from them, said Julianna S. Gonen, director of federal policy for the National Lesbian Rights Center. The threat of losing it “is so serious that hospitals will likely comply before they risk being revoked from the programs.”

Experts said the White House could also seek a federal determination that such care is dangerous or experimental, which would ripple through federally funded programs.

Alejandra Caraballo, a clinical instructor at Harvard Law’s Cyberlaw Clinic, said for many health care providers, “when the risk is losing your federal funding — which means your ability to operate — it’s easier to turn away a trans patient “.

The Trump administration could also back down federal regulations which prevents healthcare providers from denying care to transgender patients if the same type of care is provided to others. However, California has them own rules prohibiting health plans from denying care based on gender identity.

The Trump administration may also seek to restrict hormone therapy through Food and Drug Administration regulations, some believe. However, Amanda McAllister-Wallner, interim executive director of the consumer advocacy group Health Access California, said trying to identify who provides “gender-affirming care” could be thorny for federal officials because such interventions they are also used for other conditions.

“It’s not necessarily obvious – was this service provided because of someone’s diagnosis of gender dysphoria or for some other reason?” McAllister-Wallner said.

A study of insured patients published in JAMA Network Open found that, over the past year, breast reductions for trans youth far outnumbered those for non-transgender boys. The researchers said surgeries for transgender teens were “infrequent and almost entirely chest-related procedures” and found no surgeries on trans youth 12 or younger.

Before Election Day, Bamby Salcedo planned to push for improvements in gender-affirming care by Medi-Cal Initiative called CalAIM. The election put that effort on the backburner, said Salcedo, president and chief executive of the TransLatin@ Coalition, an advocacy group founded by transgender women in LA

Following that, Salcedo continued to push for an LA County budget allocation to support the needs of trans people, saying local government needs to step up. And she was also busy planning a fashion show celebrating 15 years of the organisation, calling it a chance “like a night to bring joy to our people”.

“Any way possible, we’re going to get through this,” she said.

Mars Wright, poses for a photo. Wright was able to get body masculinization surgery through Covered California insurance

(Gina Ferazzi/Los Angeles Times)

Wright was among the designers featured at the event. Before having his surgical procedures, he said, “I was scared until now. I was afraid to wear clothes I liked. I was afraid to go to the beach.” Now, he joked: “I can’t keep my shirt on.”

“I’m in a place where I like being trans.”