The House of Representatives passed a massive bill at 7 a.m. after debating all night, which is expected to add $2.4 trillion to the national debt by increasing spending as well as cutting taxes. The bill will be financed partly with debt and partly with deep cuts to federal health care programs, including cuts to gender-affirming care for trans people, including adults, in federal insurance programs.

A provision in the bill – which is being called the “Big Beautiful Bill” by supporters – bans Medicaid (a joint federal-state program that provides health care to people with low incomes) and CHIP (a program that provides health care to children and pregnant people with low incomes) from reimbursing for gender-affirming care (including puberty blockers, hormone therapy, and surgery) for trans people of all ages.

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The bill is already advancing in the GOP-controlled House.

Another provision in the budget bill prohibits plans offered on the Affordable Care Act (ACA, or Obamacare) exchanges from covering services related to a “gender transition procedure,” according to the Congressional Equality Caucus. This will also affect health care plans that aren’t offered on the exchanges but that are required to meet the same coverage standards.

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This is in addition to $500 billion in cuts to Medicare (health care for the elderly) and massive cuts to Medicaid that will remove coverage for 8.7 million Americans.

According to the Williams Institute, Medicaid provides health care to 152,000 transgender Americans, and fewer than half live in states that cover gender-affirming care through Medicaid.

“If the GOP Tax Scam becomes law, more than 13,700,000 Americans will lose their health insurance,” out gay Rep. Mark Takano (D-CA) said in a statement. “But that doesn’t matter to Republicans in Congress—they need those cuts to pay for their billionaire buddies’ tax cuts. Attacks on the trans community are just the cherry on top for them.”

“Congress should be working to make healthcare more affordable, not banning coverage of medically necessary care or pulling the rug out from underneath millions of Americans who rely on Medicaid. If we really want to honor the idea of freedom our nation was founded on, we have to protect every American’s right, including transgender people’s right, to access evidence-based care without government interference.”

Initially, the bill only banned coverage of gender-affirming care for transgender minors. But a manager’s amendment was added late Wednesday night to shore up support among the far-right that removed the words “for minors” from that part of the budget bill.

The bill passed after over 24 hours of debate in the House, which started at 1 a.m. on Wednesday. It almost didn’t pass because Republicans have a very narrow majority in the House, and some conservatives were worried about adding to the national debt. But the White House warned congressional Republicans that voting against the bill would be considered “the ultimate betrayal,” the Washington Post reports, which brought the few Republicans who were worried about increasing the national debt in line with the president’s agenda.

The bill ultimately passed early this morning by one vote, 215 to 214. All House Democrats voted against the bill, and they were joined by just two Republicans. Almost all House Republicans voted for the bill.

The bill now goes to the Senate, where Republicans hope to pass it under the reconciliation process. Reconciliation allows some budget bills to pass without the possibility of a filibuster, meaning that only 50 senators will have to vote to pass them instead of 60. There are currently 53 Republican senators.

The president provided many of the ideas for the bill and has been supportive of it, making it likely that he will sign it into law if it passes Congress.

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