Another doctoral candidate in economics, Abigail Dow of Boston University, found that as the price of child care rose, birthrates fell as families chose not to have children, stop at one child or delay pregnancy. Yet it may take decades to fully understand how these choices will shape the economy as today’s younger generations move through their peak childbearing years, said Kenneth Johnson, a demographer at the University of New Hampshire.

In interviews with couples in their 20s and 30s, many said they wanted to reach key milestones before having children, such as buying a house, paying off student debt or making enough money to afford child care. Others prioritize travel or financial stability. All said they were unwilling to compromise on these goals, even if it meant delaying parenthood indefinitely or not having children at all.

The Cost of Having a Child

Child care is often the second-biggest expense a family faces, after rent or a mortgage, said Karen Benjamin Guzzo, a family demographer at the University of North Carolina at Chapel Hill. The lack of affordable child care has long been a problem, Dr. Guzzo added, and as everyday costs like groceries, utilities and health care rise, child care becomes one more weight on already stretched budgets.

The average annual cost of care for one child in the United States was about $13,000 in 2024, up nearly 30 percent from 2020, according to Child Care Aware of America, a nonprofit group. And as the summer approaches, camps and programs can add up to more than $1,200, on average, for the season. This cost alone is keeping three out of four families from enrolling their children in traditional summer programs, according to Boys & Girls Clubs of America.

Even before a child arrives, the costs rack up. A study by the Peterson-KFF Health System Tracker published last year found that the average additional out-of-pocket cost for patients with employer insurance who gave birth was nearly $3,000 in the United States.

The Trump administration’s attack on gender-affirming care for minors bears all the hallmarks of its approach to healthcare policy.

Although it purports to reflect rigorous science, it’s almost entirely fact-free — indeed, replete with misinformation and disinformation. It ignores the procedures required by law for issuing major policy directives, but relies on bluster and threats to force its targets to comply with its orders, trampling the rule of law. It claims to be concerned with protecting the health of patients, but it puts them at risk.

And it has experienced a sturdy pushback from judges.

The most recent example is a ruling Saturday from Federal Judge Mustafa T. Kasubhai of Eugene, Ore. Kasubhai summarily invalidated a Dec. 18 declaration issued by Health and Human Services Secretary Robert F. Kennedy Jr. purporting to find that gender-affirming care for minors falls below the standard of healthcare for hospitals and threatening to terminate Medicaid and Medicare funding for those that deliver it.

Kasubhai’s ruling came in a lawsuit brought by 19 states, including California, and the District of Columbia, challenging Kennedy’s declaration. His ruling ticked all the relevant boxes.

The case, he wrote, shows how “a leader’s wanton disregard for the rule of law causes very real harm to very real people… When a leader acts without authority and in the absence of the rule of law, he acts with cruelty.”

He rejected the government’s terminology for the therapies and treatments at issue — that these are “sex-rejecting procedures” — and stated he would use the term “gender-affirming care” instead, because “in this Court all people will be treated with dignity.”

He specified the harm confronting patients and their parents seeking such care after consulting with their physicians, noting that by Kennedy’s own estimate, more than 30 hospitals and hospital systems had ceased providing gender-affirming care to minors after Kennedy’s declaration was published.

Most of those institutions were reacting not to any change in healthcare law, but to Kennedy’s threat to exclude them from Medicaid and Medicare, a seldom-imposed penalty that could force some to shut down. Kennedy’s declaration confronted healthcare providers with “the Hobson’s Choice to either stop providing gender-affirming care for minors or risk the loss of critical funding necessary to operate at all.”

Although the law sets forth detailed procedures that must be followed before withdrawing Medicaid or Medicare funds, Kasubhai noted, Kennedy’s declaration aimed to circumvent all that: “Immediate compliance was demanded.”

And he took a swipe at the Trump administration’s “break it and see if they can get away with it” approach to the law, citing its “repeated flouting of court orders and the rule of law.”

As Kasubhai observed, despite its legal feebleness, Kennedy’s declaration and its explicit threat has had a concrete impact on the provision of gender-affirming services to American youths. Numerous hospitals terminated or limited their services out of fear of devastating financial consequences if the government followed through.

Some hospitals, however, reversed course under pressure from patients’ families or court orders. Among them were Children’s Hospital-San Diego and Children’s Hospital of Orange County, which are both affiliated with Rady Children’s Health. But Superior Court Judge Matthew Braner of San Diego ordered the programs to continue at least until a court hearing next month.

At an earlier hearing, a Rady lawyer told Braner that the system was at “catastrophic risk” of losing its funding if the government pursued its campaign. Braner said he recognized that due to the government’s threat to Rady “you are between a rock and a hard place,” but questioned whether the threat was imminent: “The issue is how close is the rock and how close is the hard place.”

Kennedy’s declaration has roiled gender-affirming programs nationwide. Children’s Hospital Colorado suspended those services in January; that decision was upheld by a state judge, but the Colorado Supreme Court is pondering whether to order the services to resume.

Some providers suspended or terminated their services even before Kennedy’s Dec. 18 declaration, but after President Trump issued an executive order on Jan. 28, 2025, charging that medical professionals are “maiming and sterilizing a growing number of impressionable children under the radical and false claim that adults can change a child’s sex through a series of irreversible medical interventions.”

Trump ordered government agencies to investigate such services provided by recipients of federal funds. He specifically ordered Health and Human Services to look into whether Medicaid and Medicare rules could be deployed against those providing the services.

Trump’s order seemed to be an outgrowth of what I called a “deranged and despicable” claim he uttered during his presidential campaign that schoolchildren were being abducted by school authorities and subjected to gender surgery. This was a product, I wrote, of “Trump’s fantasyland”: No such incidents are known to exist.

More than 20 hospitals and health systems rolled back or suspended their transgender services for minors after Trump’s order. Among them was Children’s Hospital of Los Angeles, which entirely terminated all its gender affirming services for minors in July and remains the only major California institution to have done so.

The government’s threats, Children’s Hospital executives wrote in a staff email announcing the closure of its gender-affirmation clinic in June, are “no longer theoretical”; they are “threatening our ability to serve the hundreds of thousands of patients who depend on CHLA for lifesaving care.”

Some institutions have tread a narrow path around the threats from Trump and Kennedy. The executive order and Kennedy declaration both define gender-affirming care as the use of puberty blockers, hormone treatment, and surgery. Kaiser Permanente and Stanford Medicine, among other providers, have said they would cease surgical interventions for minors but continue the other therapies, knowing that gender-affirming surgical operations on minors are almost never performed.

Kaiser told me through a spokesman that it continues to provide gender-affirming care “aligned with state law and the applicable standards of care, and tailored to meet the needs of each patient.”

According to a 2024 study by researchers at Brown and Harvard of some 23 million insured minors, the prevalence of surgery among those aged 15 to 17 was 2.1 per 100,000 patients, or about 2 thousandths of a percent, 0.1 per 100,000 among those aged 13 or 14, and zero among those 12 or younger.

The statistics indicate that “concerns around high rates of gender-affirming surgery use, specifically among [transgender] minors, may be unwarranted,” the researchers concluded, adding that the low rate “likely reflects adherence to stringent standards of gender-affirming care” in the medical profession.

The threat to drive providers of gender-affirming care for minors out of government healthcare programs isn’t the only weapon the Trump administration has deployed. The Department of Justice issued subpoenas last year to more than 20 doctors and clinics, seeking evidence of healthcare fraud and other legal offenses. The targets, according to then-Atty. Gen. Pam Bondi, were “medical professionals and organizations that mutilated children in the service of a warped ideology.”

At least four federal judges blocked some of those subpoenas as flagrantly illicit overreach. Two questioned the DOJ’s integrity, with one warning that a federal official’s inaccurate declaration could be interpreted as perjury. Another implied that a DOJ filing in his courtroom might have reflected “deliberate misuse … of court procedure.”

In January, the DOJ backed away from its demand for medical records that identify young patients who received gender-affirming care from CHLA; its action was part of a settlement with parents of transgender minors who feared that the subpoenas could be used to bring criminal charges against the parents of transgender children.

The campaign to undermine transgender treatments is sure to continue, in part because Republicans see transgender rights as a potent wedge issue to keep conservatives in their camp. They have a friend in the Supreme Court, which last year blessed a Tennessee law that banned puberty blockers and hormone treatments for minors experiencing gender dysphoria.

The 6-3 ruling drew a ringing dissent from Justice Sonia Sotomayor, who wrote that the court thereby “abandons transgender children and their parents to political whims.” With those words, she defined the Trump administration’s approach to healthcare in a nutshell.