Washington lawmakers are considering a bill that would require medical insurance companies in Washington to cover up to a year’s supply of hormone replacement therapy, or HRT, at a time.

Bill sponsor Rep. Nicole Macri, D-43, introduced the bill after the state’s LGBTQ Commission ran a broad community survey and heard from trans and nonbinary people in Washington worried the federal government could restrict their access to hormones.

“This is one issue that came up around access to gender-affirming healthcare,” she said. “We heard concerns about privacy and confidentiality, having consistency in care, and increased bias and discrimination,” she said.

Under Macri’s bill, patients could pick up to 12 months of estrogen from their doctor or pharmacist, and 6 months of testosterone. Testosterone is more limited because it’s a steroid and technically a Schedule III drug under federal law. It’s not dangerous at a clinically appropriate dose, but testosterone is abused for sports doping, and can raise the risk of heart attack or stroke in excess. 

To her knowledge, and the knowledge of trans advocates like Danni Askini, executive director of the trans advocacy group Gender Justice League, it is the first bill of its kind in the US.

Similar to a 2017 Washington law that compelled insurers to cover a year of birth control, HB 1971 provides a safeguard against potential federal restrictions to a medication that needs to be taken regularly. 

If passed, HB 1971 would go into effect next year.

Six weeks into his second term, President Donald Trump has signed executive orders to federally redefine sex, kick trans people out of the military and from sports, and ban federal support for transgender care under the age of 19. Written in extreme, sensationalist terms, Trump’s flawed pronouncements have hit snags in the federal courts; judges have blocked several after finding them unconstitutional, including one in Seattle last week. 

However far these cases may go, and how they will end, is up in the air; while Trump has not tried to ban trans care for all adults, he’s willing to draw the line at 19, he’s framed trans health care in terms of surgical mutilation and chemical castration, and has issued all matter of policy by decree. For this reason, “stocking up” on medications has been seen since the election as a wise decision in the trans community, as well as a measure of literal self-preservation.

Some changes from hormone replacement therapy, like the growth of breast tissue, or a deepened voice, are not undone when someone stops their medication. But even a short lapse in treatment can begin a kind of reversion. Hormones influence how body hair grows and where fat settles on the body. They’re subtle characteristics on their own, but taken together they impress gender and set the body into a new mold. For trans people, this is a blissful experience that alleviates gender dysphoria; the reverse is a kind of hell that can put a trans person at higher risk of harassment and of suicidal ideation.

“For those of us the worst case scenario is getting this taken away from us, having backstocks let us keep that worry from the forefront of our mind,” says Samantha, a 31-year-old trans woman in Washington who does not want to use her last name because she is a federal employee. 

Samanatha is already stocking up on her medication, which she pays for out of pocket at an online pharmacy, and is considering a surgical implant to replace her daily pills, a pellet that releases hormones over months.

Heather Johnson, of Port Townsend, says anything to reduce the risk of losing access to care would bring her peace of mind. She’s on a federal insurance plan and is concerned about possible new exclusions to trans care. She’s hoping state laws could serve as a backstop.

“Losing access to HRT, for me, would be a nightmare,” she said in a text message. “It’s literally the kind of thing that keeps me up at night.”

But HRT is prescribed for far more than gender dysphoria, and most people undergoing this treatment are cis, not trans. Estrogen can ease menopause symptoms in cis women, and prevent osteoporosis. Cis men with hypogonadism, or low T, take testosterone to boost energy and sex drive. The vast majority of people who take HRT are cis, and like birth control, this medication only works if taken consistently.

Insurance companies like to keep tight restrictions on refills because it cuts into their profits. Authorizing more than a month, or three months, of a drug at a time opens the possibility of paying for drugs they didn’t need to pay for (say someone picking up a script one day, and cancels their plan, or dies, the next day). Prescriptions can also change, rendering already issued drugs useless. However, hormone regimens are fairly consistent once established. The benefits are obvious for patients. An extra bottle, or vial, of medication, reduces the chance someone will miss a dose when a drug is on backorder, or when life gets in the way of visiting the pharmacy. 

Macri says that the LGBTQ commission also heard from trans people in rural areas concerned about getting medications from local providers, and undocumented immigrants who feared the separate federal crackdown on them may impede their care in some way. 

Macri’s bill does not change how doctors administer HRT, but during a hearing last month, Republican Rep. Michelle Caldier suggested it could, asking if this bill would allow a 13 year old to go to a School Based Health Center and acquire a year of hormones without their parents knowledge or consent.

Generally, kids don’t control their health care. Washington State makes a few exceptions to guarantee confidential access to therapy and counseling, STI testing and birth control, but this short list does not include hormones. In rare cases, doctors provide medical care to kids under the state’s mature minor doctrine, but that’s often for those living alone and financially independent, not living comfortably at home with their parents. Even so, a doctor or hospital decides who they are willing to treat. In terms of gender care, they’d also look to the professional standards set by the World Professional Association of Transgender Health, which recommends involving parents if it does not bring direct harm to the child. Nothing suggests a kid could easily take hormones without their parents knowing.

Last Friday, HB 1971 moved out of the House Appropriations committee on a party line vote. To stay alive, it needs to be voted out of the House by next Wednesday, March 12. Along with dozens of other bills, HB 1971 is with the Rules Committee and should be up for a vote on the House floor this weekend or next week, where Republicans are likely to tack on amendments to it.