Iowa is one signature away from enacting a law that would limit transgender people’s access to necessary health care.

The law would allow government entities to opt out of using public insurance dollars, including Medicaid, to pay for any kind of transition-related care. This language was tacked on as an amendment to a health and human services appropriations bill late in the process, LGBTQ rights advocates said, without any committee hearings or public comment process. Lawmakers approved the legislation on Saturday.

Now, it’s up to Gov. Kim Reynolds (R). The governor hasn’t signed the legislation yet, and LGBTQ groups are talking to her staff to convince her not to do so.

Keenan Crow, director of policy and advocacy at One Iowa, an LGBTQ advocacy group, told ThinkProgress that transgender Iowans are waiting for an answer.

“I don’t think people have a whole lot of other options. People on Medicaid don’t have the means to pay for care out of pocket and so making other arrangements is almost certainly out of the question, so what we’re looking at is folks who have care scheduled already really just worrying,” they said. “And in some cases they’re devastated this might not actually happen for them. They feel like it’s very unfair targeting of them based on not medical consensus but based on biases and stereotypes against trans people.”

The new legislation came a couple months after a big court win for transgender Iowans. In March, the Iowa Supreme Court struck down the state’s ban on Medicaid coverage for sex reassignment surgery. In a unanimous ruling, the court sided with two transgender women whose health care providers said the surgery was necessary to treat their gender dysphoria.

Crow said that One Iowa expected Republicans would wait about a year to introduce legislation like this and only heard serious discussion of this amendment in the past couple of weeks. Crow said it could have been much worse, since Republicans initially sought to remove gender identity protections from the Iowa Civil Rights Act.

“If that had happened, it would have been absolutely catastrophic,” Crow said.

After speaking to more sympathetic Republicans, Crow said the language changed to effectively reverse the recent court victory and not affect broader nondiscrimination protections for transgender people, including housing and employment. The current language adds an exemption to the Iowa Civil Rights Act  that says a “state or local government unit or tax-supported district” is not required to support transition-related care.

The language specifically refers to “sex reassignment surgery” and “any other cosmetic reconstructive or plastic surgery procedure related to transsexualism, hermaphroditism, gender identity disorder, or body dysmorphic disorder.”

Sharon Malheiro, an Iowa lawyer and advocate for LGBTQ rights, told the Des Moines Register that the language in the bill is close to the language the state Supreme Court considered discriminatory.

“This particular section just picks out one class of citizens to deny access to service for and I believe that violates the equal protection clause of the Iowa Constitution,” she told the Register.

Crow said they have been advocating for transgender people’s access to health care with the governor’s staff and reminding them that groups such as the American Medical Association (AMA) are supportive of transition-related care.

“Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people and has called for health insurance coverage for treatment of gender dysphoria,” a 2019 issue brief from the AMA states.

The Human Rights Campaign also spoke out against the legislation. “As a native Iowan, it’s disturbing to see lawmakers in my home state trying to roll back the clock on progress and discriminating against transgender people at the eleventh legislative hour,” JoDee Winterhof, HRC senior vice president for policy and political affairs, said in a statement. “These lawmakers should be focusing on ways to improve the health and wellbeing of all Iowans, not targeting transgender people to win cheap political points. Now, Gov. Kim Reynolds should reject this patently discriminatory legislative language.”

In addition to the language on transition-related health care, the appropriations bill includes a provision to block Planned Parenthood from participating in state-funded sex education.

The move comes as the Trump administration takes steps that LGBTQ advocacy groups say will enable discrimination against queer and transgender people. The Trump administration on Thursday finalized a rule that would let health care workers refer to religious or moral objections when they don’t want to deliver certain health care services. The National Center for Transgender Equality has said it is concerned that this will affect transgender people’s access to health care.

BREAKING: The Trump-Pence admin just opened the door to more health care providers denying transition-related care, all while claiming that they lack evidence that religious bigotry harms LGBTQ people and other minorities. & : you’re wrong.

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— National Center for Transgender Equality () May 2, 2019