The overlapping issues of health care and employment discrimination remain pivotal ones for transgender communities. They became more so last month, when the Trump administration decided to allow states to institute work requirements for Medicaid.

The unemployment rate for trans people is three times higher than the national average, according to a 2015 survey produced by the National Center for Transgender Equality — a rate that results, in many cases, from anti-trans job discrimination. These new rules create a double bind for the most vulnerable trans people: Find work amid rampant prejudice and mistreatment, or lose critical medical coverage.

In Kentucky, the first state to adopt work requirements, one in four transgender people report losing a job, being passed over for a promotion or not being hired because they are trans. The majority of states considering adopting work requirements are among the 30 in which gender identity is not considered a protected category. Of the 10 states currently carrying out or proposing Medicaid work requirements, only two — Maine and Utah — have an employment nondiscrimination law in place that protects trans workers. In contrast, Arkansas and North Carolina have state-level bans on local nondiscrimination ordinances that would safeguard the rights of queer and trans communities.

Statistics regarding transgender people who lose their jobs because of their gender identities reveal only the cases in which such bias was blatant. Lost within these numbers are the more ambiguous stories — of managers who may have rejected a request for a uniform that reflected an employee’s gender, workers terminated for requests to change their names on internal documents or employees whose presence was shown, through the actions of colleagues and superiors, to be unwelcome.