Introducing: The Gender Affirming Care Initiative
Why We’re Building a Gender Affirming Clinic Outside the System
For the last several months I've been working with a group of local health providers and other volunteers to create a gender affirming care clinic in Boone. The goal is straightforward: a place that can offer HRT and other gender affirming care at prices people can actually afford. But the structure we've chosen is deliberate, and it's worth explaining why.
We're building this clinic to be separate from any major health network, and not dependent on state or federal funding. That second part is the piece that surprises people. Most clinics want federal dollars, especially when aiming to offer free or low cost care. Why would we turn away from them on purpose?
Because right now, federal funding has become the lever being used to shut this care down.
How the pressure actually works
The current strategy at the federal level mostly isn't an outright, nationwide ban on gender affirming care. It's quieter than that, and in some ways more effective. The federal government has moved to tie a provider's ability to bill Medicare and Medicaid to whether they provide certain gender affirming services. Proposed CMS rules would bar participating hospitals from providing gender-affirming treatments and could lead to decertification from Medicare and Medicaid even when care is paid for with other funds.
For a hospital, that's an impossible math problem. Medicare and Medicaid are often the majority of a large system's revenue. So when the choice becomes "keep offering this care and risk your entire funding base" or "quietly stop," most institutions stop. More than 40 hospitals have already paused or ceased some gender affirming care, including in states where the care is fully legal. The care didn't become illegal in those places. The institutions just couldn't afford the risk.
Think of it like a house wired into the city power grid. As long as you're plugged in, whoever controls the grid can flip your breaker whenever they decide they don't like what you're doing. It doesn't matter that your lights were never against the rules. The leverage is the connection itself.
A clinic that runs on its own power can't be switched off that way.
What's happening here in North Carolina
North Carolina passed its own restriction: HB808 bars medical professionals from providing hormone therapy, puberty-blocking drugs, and surgical gender-transition procedures to anyone under 18, with limited exceptions, and it became law after the General Assembly overrode Governor Cooper's veto. The law does include a carve-out: young people who had already started a course of treatment before August 1, 2023 can continue receiving it, and it doesn't restrict mental health care. (The Campaign for Southern Equality)
That's the law on paper. What's happened since is a good illustration of why the law isn't the only thing that determines who can actually get care.
Take Atrium Health, the state's largest provider, now part of Advocate Health. In August 2025, Atrium stopped providing gender-affirming care to patients under 19, a step that goes beyond what state law requires, since the law only covers minors. UNC Health did the same thing a few months later. UNC began notifying patients in September 2025 that care would be discontinued, with no public announcement, and a spokesman said concerns over the federal regulatory environment prompted the decision.
Novant and Duke are the quieter parts of this story. When reporters asked both systems whether they had changed their policies, Duke Health and Novant Health did not respond to questions about the status of their care. Duke in particular declined multiple requests for comment on its policies or on whether it would take patients who had lost access elsewhere. The point is that families can't get a straight answer, and silence from a major system is not something you can build your healthcare around.
And it isn't only the hospitals. North Carolina's own State Employee Health Plan stopped covering gender-affirming care, leaving state workers without coverage for it. So the pressure is coming from several directions at once: a state law, a state insurance plan, federal funding threats, and institutions quietly going further than any of those require. (The Assembly NC)
Every one of these decisions has something in common. They were made by large organizations weighing their funding and their exposure, and trans people were the variable that got cut to protect everything else. A clinic that isn't wired into any of those systems doesn't have that calculation to make.
Why this is the answer
At the federal level, the strategy isn't usually a direct ban. It's funding used as a lever, with Medicare and Medicaid certification held hostage so that institutions decide for themselves to stop. At the state level, North Carolina has a law on the books, a state insurance plan that dropped coverage, and major health systems that quietly cut further than the law required. None of these forces is the whole story on its own. Together they've built an environment where care keeps disappearing without anyone ever having to ban it outright.
What every one of these pressure points has in common is that they only work on organizations that have something to lose. A hospital with billions in federal reimbursement. A state plan answering to the legislature. A health system protecting its other service lines. Each of them, when squeezed, found it safer to drop trans patients than to risk the rest. The care was never the problem. The exposure was.
So we're building something with nothing to squeeze. No federal reimbursement to threaten, no parent network to pressure, no state funding to freeze. When you aren't plugged into the grid, there's no breaker for anyone to flip. It's the most stable foundation available right now, and in a moment like this one, stability is the whole point. The people who need this care can't afford to keep losing it every time a larger institution recalculates its risk.
This is hard to build, and we won't pretend otherwise. Affordability without big institutional money means leaning on community, on volunteers, and on each other. But it also means that once this clinic exists, it stays. It answers to the people it serves and to no one with the power to take it away.
