Trump’s Executive Order Spared LGBTQ People. Trumpcare Could Kill Them.

Donald Trump.

Photo by Chip Somodevilla/Getty Images

As part of Thursday’s National Prayer Day celebration at the White House, Donald Trump signed an executive order that purports to protect religious liberty from government overreach. The order aims to free churches from the Johnson Amendment, allowing them to endorse political candidates, and orders federal agencies to “consider” further weakening the contraceptive mandate. What it doesn’t do is directly target LGBTQ rights. Although Politico reported that Trump was poised to let federal employees and contractors discriminate against LGBTQ individuals, the order does no such thing. Trump, it seems, decided to grant LGBTQ people a reprieve.

The House of Representatives, however, was not so munificent. As Trump signed his Thursday order, Republican leaders were whipping votes for the American Health Care Act, aka Trumpcare, which passed the House a few hours later. Among its many egregious flaws, Trumpcare would have catastrophic consequences for LGBTQ people across the United States. It is essentially a sideways attack on the LGBTQ community. And if it is signed into law, thousands of LGBTQ people could die.

Trumpcare hurts LGBTQ individuals in several ways. First, it guts the Affordable Care Act’s Medicaid expansion, which served as a lifeline to many sexual and gender minorities. Thanks to the ACA, the rate of uninsurance among gay and bisexual people dropped from 22 percent to 11 percent between 2013 and 2015. A significant portion of these newly insured individuals obtained care through Medicaid; the Center for American Progress estimates that today, about 1.8 million LGBTQ adults have Medicaid coverage.

That number would plummet under Trumpcare. The ACA broadened Medicaid eligibility in part by scrapping rules that allowed only low-income adults with a disability or a dependant child to enroll. Many low-income LGBTQ people don’t have children or a disability, but the ACA allowed them to obtain Medicaid coverage anyway (in states that accepted the expansion). Under Trumpcare, however, the pre-ACA rules will return in 2020. At that point, ineligible individuals won’t be immediately kicked off Medicaid—but if they temporarily obtain other insurance, they won’t be able to re-enroll.

Perversely, this policy gives patients a strong disincentive to quit Medicaid for private insurance, thereby increasing taxpayer expenses. It is also certain to harm LGBTQ people, who are more likely to live in poverty than heterosexuals. And it will create a quandary for HIV-positive people, because Medicaid does not consider HIV to be a disability—only AIDS. By allowing nondisabled people to enroll in Medicaid, the ACA solved this problem, reducing the uninsurance rate among those living with HIV. In fact, Medicaid is now the largest source of health insurance for HIV-positive people.

Trumpcare would reverse that progress. If it becomes law, an HIV-positive person with no children or disability will once again have to let their HIV progress to AIDS in order to obtain Medicaid coverage. Since HIV disproportionately burdens LGBTQ people, this turnabout will hurt them the most. Trumpcare also allows states to opt out of the “essential health benefits” protected by the ACA; many of these benefits are critical to HIV treatment. And the bill would slash Medicaid by $880 billion while capping reimbursements to the states, diminishing the quality and availability of care overall.

Naturally, Trumpcare also goes after Planned Parenthood, barring the organization’s clinics from receiving Medicaid reimbursements. Planned Parenthood serves as a refuge for myriad LGBTQ patients, who cannot find or afford appropriate treatment elsewhere. Its clinics provide free or low-cost preventative care and testing to LGBTQ people that literally saves lives. (The infamous HIV outbreak in Austin, Indiana, occurred after the state shut down the county’s Planned Parenthood clinic; it was the only clinic in the county that provided free HIV testing.)

Planned Parenthood is especially vital for transgender patients. A number of its clinics provide transition therapy to transgender patients and specialize in addressing trans patients’ unique medical needs. If these clinics shutter—as many could under Trumpcare—thousands of trans patients, especially those in rural communities, will have nowhere to turn. Nor will they be assured of nondiscriminatory care: The Trump administration is working to roll back the ACA’s protections for transgender and gender non-conforming patients.

Trumpcare contains one last indignity for LGBTQ people. The law would allow insurance companies to consider sexual assault and domestic abuse to be “preexisting conditions,” meaning insurance companies could charge survivors of rape and abuse higher premiums. LGBTQ people, especially trans individuals and bisexual women, are at heightened risk of sexual assault and intimate partner violence. Trumpcare will make it much more difficult for these trauma survivors to purchase affordable insurance.

LGBTQ people, of course, won’t be the only victims of Trumpcare. The plan would knock as many as 24 million Americans off of their health insurance, killing tens of thousands of people each year. It is a nightmare for all but the wealthiest Americans and constitutes an obscene devaluation of human life. Trumpcare degrades us all—but it is especially noxious for LGBTQ people, who will disproportionately fall victim to its cruelty. Trump did not revoke LGBTQ people’s rights on Thursday. But his health care law may well take their lives.