UPDATE, May 3, 6:00 p.m.: Gov. Kim Reynolds signed the Health and Human Services budget into law, including the language relating to gender confirmation surgery.

Aidan Zingler wore black to the Iowa governor’s office on Tuesday morning.

Days after state lawmakers passed an amendment that would likely block Medicaid and other public insurance from being used for gender confirmation surgery, Zingler was one of several dozen people who gathered to advocate against the proposal to the deputy chief of staff for Republican Gov. Kim Reynolds. Allies to the trans community—including ministers, child psychologists, and parents of transgender children—wore the pink, white, and blue colors of the trans flag at the 8 a.m. meeting.

Dark spots blotted the human banner, however. After receiving calls from friends terrified they will never have the chance to access gender-affirming health care if the amendment becomes law, Zingler made the decision to wear funereal colors.

“The people we’ve lost, the people who are struggling right now, and the people who are scared, I’m wearing black in mourning so they are not forgotten,” they said.

The fate of Iowa’s trans community will soon be on Gov. Reynolds’ desk, once she receives the $2 billion budget proposal for Iowa’s Department of Human Services (DHS). A last-minute amendment to the budget bill would aim to stop “sex reassignment surgery” or “any other cosmetic, reconstructive, or plastic surgery procedure related to transsexualism, hermaphroditism, gender identity disorder, or body dysmorphic disorder” from being funded through the state’s Medicaid program.

Soon after the amendment’s introduction, the Iowa Senate passed the legislation on Friday in a 31-19 vote. The house followed suit the next day, approving the budget plan by a 52-47 margin on Saturday afternoon. Not a single Democrat voted in favor of the bill, which was pushed through without a committee hearing or public testimony.

According to Keenan Crow, director of policy and advocacy for the LGBTQ group One Iowa, the budget bill has an “immediate enactment clause” attached to it. That means the Medicaid exclusions will be effectively reinstated the moment Gov. Reynolds signs the legislation. The Republican governor has 30 days from the moment she receives the bill to make the decision.

Crow claimed there’s some debate, however, about whether the amendment would outright block all medical providers in Iowa from accepting Medicaid insurance for transition care.

“It says specifically, ‘This section shall not require’ the state to provide for these procedures,” they told Rewire.News. “It doesn’t say it prohibits them from doing so, but I think the intent is to ultimately reverse that March 8 Iowa Supreme Court ruling. So we believe that DHS is likely to interpret it in that way, but we can’t say for sure how they’re going to interpret it.”

But if Reynolds signs the proposal, transgender Iowans say it would have a devastating effect on their community. Tobias Gurl, who joined Zingler in wearing black to Tuesday’s meeting, said he is $30,000 in debt because his government insurance plan wouldn’t pay to have his ovaries removed after they showed signs of being precancerous. When he got a mastectomy, he was forced to use the money his parents had saved up in case he gets married someday.

“Trans people are already regularly denied coverage, not only directly transition-related care but for any sort of basic health screenings, anything that might be tied to being transgender,” he told Rewire.News.

These stories are common among transgender Iowans. Before the Iowa Supreme Court lifted an administrative code blocking Medicaid coverage of transition-related surgeries in a unanimous ruling in March, Zingler had difficulty getting their public health plan to cover hormone replacement therapy (HRT). When they went for a breast cancer check up, Zingler said, their Medicaid insurance “tried to label it as ‘trans health’ and would not cover it.”

“They’re just checking for cancer,” Zingler said, suggesting the budget amendment may have similarly broad ramifications. “This should be covered.”

While Zingler was at least able to see a primary care physician on a regular basis, some transgender Iowans struggled to get even basic health services under the previous exclusionary policy. Zingler said a friend who had pain in his abdomen was rejected by two different hospitals before he found one that would allow him to use his Medicaid plan to pay for the emergency room visit.

When the Iowa Supreme Court ruled last month that excluding transition care from the state’s Medicaid plan is violates its civil rights act, many transgender Iowans planned the doctor’s visits they’d long been putting off. Crow said some community members had “surgeries scheduled as soon as this week,” while Gurl added that an acquaintance who had worked on Reynolds’ 2018 election campaign was looking forward to having his “first opportunity to schedule bottom surgery.”

“Now it’s about to be taken away,” Gurl said. “He’s terrified and livid.”

Although Reynolds has not confirmed whether she has received the budget bill, LGBTQ advocates are urging the governor to line-item veto the amendment as soon as the bill reaches her desk. Because the discriminatory amendment is part of a state budget, Crow said the governor “could strip out this harmful component and keep the rest.”

“We should not be singling out a group of people,” they said. “We should be deferring to the medical experts. That’s how good policy is crafted.”

While the Iowa Department of Human Services has classified gender confirmation surgeries under the umbrella of “cosmetic, reconstructive, or plastic surgery,” advocates say there’s a growing consensus among U.S. medical groups that these operations are critical for transgender patients. These include the American Medical Association, the American Psychological Association, the American Public Health Association, and the National Association of Social Workers.

The amendment’s sponsor, state Sen. Mark Costello (R-Imogene), said in floor debate Fridaythat gender-confirmation surgery is “pretty expensive” and “not a proper use of our state monies,” according to the Des Moines Register. But studies suggest it would not affect Iowans’ tax burden. When Illinois was considering whether to offer transition care through its Medicaid program, its Department of Healthcare and Family Services researched the 17 states that already do. After finding that none “have reported significant cost increases,” Illinois became number 18 earlier this year.

Similarly, when San Francisco began offering trans-inclusive health coverage for city employees in 2001, a cost estimate suggested it would lead to a monthly increase of $1.70 for those enrolled in the program. According to the Human Rights Campaign, those projections “were vastly overestimated—on a magnitude of at least 35 times over the actual costs.”

But Gurl insists the issue is about more than just the bottom line. When trans people do not have access to gender-affirming care, they are at greater risk for experiencing depression, anxiety, or suicidal ideation. In a 2018 study of 156 people who had received transition-related surgery, researchers with Essen University Hospital in Germany concluded that “around three quarters of patients showed a better quality of life” following the procedure.

“This is a real opportunity for the governor to demonstrate the care that she shows for all of Iowa’s residents,” Gurl said. “If our care is taken away, we will be left as badly or worse off than before. It’s absolutely vital that we aren’t treated like numbers on a spreadsheet, where you can knock out the most vulnerable to save a few bucks.”