Under the Affordable Care Act, healthcare options increased for transgender Americans. Likewise, as states have broadened access to Medicaid for lower-income residents, there was even more avenues for transgender health care.

But barriers to care remain, and plans to roll back rules in the ACA that aid transgender people put care up in the air for many.

A survey by the Americans for Progress from 2014 showed that the number of uninsured transgender people dropped by nearly 50% after the Affordable Care Act took affect.

But in spite of rules in place to ensure transgender coverage, individual insurers can and do have pre-ACA trans health care prohibitions in many of their policies, causing the healthcare.gov website to recommend that transgender people study the terms of coverage of plans that are interested in and look for specific exclusions, often couched using varying terms such as “gender identity dysphoria.”

Care can be further complicated by health care providers who are inexperienced in transgender health care, and rules that do not take into account specific needs for transgender people, including requirements that hormone coverage — something many transgender people will use for the rest of their lives — be re-approved on a yearly basis.

Healthcare.gov does note that some of this many indeed be “unlawful sex discrimination,” and suggested a path to filing a complaint or appeal a decision that leads to non-coverage. Unfortunately, the current administration is not the “fierce advocate” the Obama administration was, meaning that these protections may not be as strongly enforced as they were in the past.

What’s more, it is highly likely that the Department of Health and Human Services may modify the rules entirely, based on a 2015 injunction from a Texas judge that claims such care would impose on the religious freedoms of doctors.

“The court held that the regulation’s coverage of gender identity… was contrary to law and exceeded statutory authority,” said Roger Severino, the director of the Office for Civil Rights at the HHS, “and that the rule’s harm was felt by health care providers in states across the country, so a nationwide injunction was appropriate.”

It is unclear at this time where transgender healthcare stands under the ACA and other programs, with the Secretary of the HHS, Alex Azar, seemingly contradicting Severino. Azar initially claimed ignorance in a press conference when asked about the possible changes, but later had a HHS spokesperson, Caitlyn Oakley, make a statement on behalf of the department.

“HHS’s Office for Civil Rights will continue to vigorously enforce all prohibitions on discrimination in health care on the basis of race, color, national origin, sex, age and disability according to the law and court orders, before, during and after any rulemaking,” said Caitlyn Oakley.

Regardless, this leaves the care of transgender Americans in a holding pattern, and may put many at risk once again for less affordable and less effective care.