A new report from the Williams Institute has found that 276,000 transgender adults are enrolled in Medicaid. That’s about 21 percent of the estimated 1.3 million adults who identify as trans in the United States.

Of the trans people enrolled in Medicaid, 60% have clear access to coverage for gender-affirming care. However, about 27% live in states where the laws either say nothing or are not clear regarding coverage for gender-affirming care. 14% live in states that actively ban coverage of gender-affirming care for Medicaid beneficiaries.

The authors defined gender-affirming care as “a range of services, such as surgical procedures, hormone therapy, and other forms of treatment.”

The authors also pointed out that bans on gender-affirming care coverage have been overturned in court in many of the states whose laws favor anti-discrimination.

According to the report, 25 states and the District of Columbia explicitly cover gender-affirming care in their Medicaid programs, while 18 do not say anything about coverage either way, and seven actively exclude it.

The states that ban it are South Carolina, Tennessee, Texas, Arizona, Nebraska, Florida, and Missouri. Most of these states focus on specifically banning coverage for gender-affirming surgeries, but some also ban other types of gender-affirming care from being covered.

Though federal law does not explicitly require states to include or exclude gender-affirming care coverage in Medicaid programs, the study’s authors said that many state and federal laws require states give access to gender-affirming care through Medicaid.

“At the federal level, these laws and policies include statutes, like the Affordable Care Act and the Medicaid Act, as well as the U.S. Constitution,” the report stated. “In addition, a number of state-level non-discrimination statutes and constitutional provisions support access to care.”