Selina Simmons-Duffin

The most significant actions are two proposed rules from the Centers for Medicare and Medicaid Services, led by Dr. Mehmet Oz.

One rule says doctors and hospitals cannot get reimbursed by Medicaid for gender-affirming care for youth.

The other is more sweeping.

It says hospitals that provide the care would be cut off from all Medicare or Medicaid funding for everything.

Because federal funding represents so much of hospital budgets, that rule could shut down gender-affirming care for youth at hospitals if finalized.

The rules don't take effect right away.

There's a 60-day comment period, and health officials acknowledged they would face legal challenges.

Selena Simmons-Duffin, NPR News, Washington.

One rule says doctors and hospitals cannot get reimbursed by Medicaid for gender-affirming care for youth under age 18.

NPR obtained an exclusive draft of this rule in October.

The other is even more sweeping.

It says hospitals that provide this care would be cut off from all Medicare or Medicaid funding for everything.

And because federal funding represents so much of hospital budgets, that rule could shut down all gender-affirming care for youth at hospitals.

Partly Republicans don't like the Affordable Care Act, and they don't want to vote to shore it up.

They say the enhanced subsidies are just papering over the high cost of health insurance.

Also, they say that it's a really small portion of the population that relies on these plans, only about 7% of Americans.

Most people get their insurance through their jobs or through Medicaid or Medicare.

So Republicans seem to be making the calculation that even if some of their voters are on the hook for these higher premiums, it might not be enough to hurt the party politically.

24 million people were enrolled in these Obamacare plans this year, and almost all of them got these generous federal subsidies that came in during the pandemic to help keep their premium costs really affordable, like $10 a month for many people.

Those enhanced subsidies expire in a matter of weeks.