A top official at the Centers for Medicare & Medicaid Services (CMS) approved the use of federal Medicaid dollars for sex changes in Washington state while simultaneously playing a role in aggressive audits and enforcement actions targeting Republican-led states over their Medicaid practices. Rory Howe, Director of the Financial Management Group at CMS, signed the formal approval of Washington State Plan Amendment WA-24-0034 on August 13, 2024, granting federal funding for what the amendment defines as “medically necessary gender affirming care for a client with a diagnosis of gender dysphoria” under the state’s Medicaid program.