Leaked Children's Hospital of Los Angeles Email from CEO Paul Viviano, With Annotations
Sections highlighted in bold print are annotated with color commentary by MadyCast News contributor Corinne Green.
From the Desk of Paul Viviano
Gender-Affirming Care Update
Dear CHLA Team Members,
We are writing to share an important and profoundly difficult update. CHLA has determined that—under current conditions and despite significant efforts to avoid this outcome1—there is no viable alternative to closing the Center for Transyouth Health and Development, along with the Gender-Affirming Care (GAC) surgical program. As a result, the Center and program will be closing, effective July 22, 2025.
This decision does not come lightly and we realize the deep impact it will have on members of our team and community, especially following the hospital’s decision to pause and then resume new enrollments to certain aspects of CHLA’s gender-affirming care services. However, it follows a lengthy and thorough assessment2 of the increasingly severe impacts of federal administrative actions and proposed policies that have taken place since that time, including recent developments that directly affect CHLA.3
We are starting to notify patients today, and over the next several weeks CHLA care teams will be actively assisting with patient navigation and seeking to identify potential alternative providers.4 CHLA will explore reassigning impacted employees to other roles within the hospital based on needs and available funding.
Why Now
As we have shared, CHLA continues to face significant operational, legal, and financial risks stemming from the shifting policy landscape at both the state and federal levels.5 Over the past several months, California’s deepening budget crisis, President Trump’s executive orders, proposed federal legislation and rulemaking, and growing economic uncertainty have made the situation even more dire. Alone, each of these developments would pose a significant challenge to CHLA—together, they are creating an immediate and unsustainable strain on our fiscal resiliency, threatening our ability to serve the hundreds of thousands of patients who depend on CHLA for lifesaving care6 and to maintain scientific research that is so crucial to our mission.
In the end, this painful and difficult decision was driven by the need to safeguard CHLA’s ability to operate amid significant external pressures beyond our control.7 The July 22 sunset date was chosen to help give patient families adequate time to plan for moving care to providers less impacted by the legal and financial pressures our health system faces.8
External Factors Impacting this Outcome
When the executive order impacting GAC was first issued, there was significant uncertainty about how the order would be interpreted and enforced.9 CHLA’s earlier decision to pause initiation of new hormonal therapies for patients seeking GAC (as well as surgeries for minors) reflected that uncertainty and how it would impact hospital operations. A few weeks later, CHLA was able to resume these therapies after reviewing temporary restraining orders on the executive order, and in light of commitments from the state Attorney General’s office to seek additional protections for CHLA and our patients.10
However, more recently, federal agencies—including the Department of Justice (DOJ), Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS), the FBI, and the Federal Trade Commission—have taken actions to clarify the executive order impacting GAC, including severe consequences for hospitals and other providers that do not comply.11
These clarifications include messages sent directly to CHLA12 and/or disseminated nationally:
Letters dated May 28, 2025, from CMS and HHS demanding data on hospital quality standards and finances related to GAC within 30 days of receipt and warning of “new policies and oversight actions...to hold providers...accountable” if changes to care practices are not made to come into alignment with the new HHS review.13
A memo from U.S. Attorney General Pam Bondi in late April directing DOJ attorneys to enforce the Administration’s executive order on GAC through federal criminal prosecutions of GAC providers; calling for False Claims Act investigations of GAC providers; and stating the DOJ was “eager” to work with whistleblowers to identify these providers.14
An HHS review published in May dismissing current evidence-based care protocols and standards of care while promoting alternative best practices for the treatment of pediatric gender dysphoria, which included dozens of references to CHLA and the Center for Transyouth Health and Development.15
Taken together, the Attorney General memo, HHS review, and the recent solicitation of tips from the FBI to report hospitals and providers of GAC strongly signal this Administration’s intent to take swift and decisive action, both criminal and civil, against any entity it views as being in violation of the executive order.16
In addition, if CMS were to give CHLA an “Immediate Jeopardy” designation—the highest level of deficiency identified by CMS—in connection with its continued provision of GAC to minors, CHLA would be suspended or terminated from our ability to participate in Medicaid/Medi-Cal, posing an existential threat to our hospital operations.17
These threats are no longer theoretical. The federal government has already cut off hundreds of millions of dollars from U.S. academic and research institutions for noncompliance with executive orders, often with little to no warning. Many of these organizations are also facing inquiries from agencies such as the DOJ and HHS.
Why CHLA
We understand that other hospitals may not yet be taking this step, and this may prompt questions about why CHLA is doing so. It’s important to share why CHLA’s ability to continue serving children and families across the region18 is uniquely tied to state and federal support:
CHLA relies on federal funding more than any other pediatric hospital in the state.19 Over 65% of our annual funding—$1.3 billion out of $2 billion—comes from federal sources. For the past several years, CHLA has faced increasing financial strain due to this reliance on government funding and a payer mix heavily weighted toward Medi-Cal, which has been steadily lowering reimbursement for care of California’s sickest children. This environment has contributed to CHLA’s bond rating being downgraded to a level that is now below investment-grade, reflecting the hospital’s less stable financial position.
Should CHLA lose access to federal funding, the hospital’s cash reserves would only be able to sustain operations for approximately 50 days.20 Our fragile fiscal position, combined with our reliance on threatened federal funding, means CHLA is uniquely vulnerable to regulatory and policy changes impacting Medicaid participation and reimbursement. Long periods of uncertain reimbursement policy would threaten CHLA’s ability to remain open.
Threats to CHLA’s funding also directly threaten access to essential care for hundreds of thousands of Southern California children, adolescents, and young adults, who are disproportionately low-income and underserved.21 As the largest pediatric safety net provider in California, CHLA accounts for nearly 40% of pediatric beds in LA County. We fully recognize that this decision will have a real impact on a population that is itself vulnerable, which makes this outcome all the more heart-wrenching. But CHLA has a responsibility to navigate this complex and uncertain regulatory environment in a way that allows us to remain open as much as possible for as many as possible.22
Again, there is no doubt that this is a painful and significant change to our organization and a challenge to CHLA’s mission, vision, and values.23 Our colleagues, both within and outside of the Center for Transyouth Health and Development and the Division of Adolescent and Young Adult Medicine, are passionately committed to caring for youth, and we expect many other team members will also have a range of emotions and reactions that to this decision and the moment in which it is being made. For more than 30 years, CHLA has provided this high-quality, evidence-based, medically essential care for youth, young adults, and their families. CHLA is immensely proud of this legacy of caring for young people on the path to achieving their authentic selves. Despite this deeply held commitment to supporting LA’s gender-diverse community,24 the hospital has been left with no viable path forward.25
We understand that this news will be surprising and unwelcome for many, and that you may have additional questions. We will be hosting a series of team member forums over the next few days to hear your thoughts and concerns while addressing some of your questions.
What significant efforts? What litigation did you file? Where’s that collaboration with the CA AG you mention later? Show us the emails and call logs you sent to the Governor’s office. Show us correspondence with TLC, EQCA, TransLatina Coalition, and the LA LGBTQ Center. Show us your pitches to rich foundations. Show us the legal strategy you drew up but just couldn’t try.
Show us the assessment. Did you contract it out? Use in-house counsel? Was it the same team or a different one from the last time you ended care? If it was the same team, what did they do better this time?
You provide absolutely zero evidence of this. Public statements, letters blasted out to everywhere, etc. are not direct legal demands to CHLA.
Seeking to identify? Potential alternative providers? This was a “lengthy and thorough assessment” but you didn’t bother to make a plan for your patients? At all? You don’t know where else they can go yet? Fake as fuck. You aren’t doing shit.
What state policy landscape shifted that isn’t regular ass approps shit? If it’s approps what other programs did you consider cutting? Did you cost out ending cancer treatment? Did you weigh ending trans care against closing the ER? What are your legal risks from California? You said the AG had backed you up.
Do trans people not depend on CHLA for lifesaving care? Is their healthcare less lifesaving than other care? Show us the budget estimates where you axed your “crucial” scientific research instead of trans people so we can evaluate your call.
If 10 days is “adequate time” for trans people to find new providers, how is it that you didn’t identity these providers during your lengthy and thorough assessment? Are you magically going to become better at finding them in the next ten days?
Which providers are less legally impacted? The fake shit you identify below includes numerous threats to providers broadly as a class. Does a small family practice in Delano have a bigger legal team than you do?
At no point ever was there any uncertainty about how the administration was planning to interpret and enforce their policies. Absolutely nobody believes this. Their rhetoric, threats, and actions have been transexterminationist since long before the election. If your attorneys were uncertain about this your attorneys suck shit.
If restraining orders gave you confidence, did you ever file for one? Can we have the case number? Did the AG seek additional protections? What were they? What’s he say? Surely you talked to him. He’ll sue Trump over electric vehicles and the troop mobilization but the guy who promised to protect you and your patients crawfished on you? We all know you’re full of shit.
Bullshit. Everyone has known what their intentions were the whole time. Everyone has been familiar with the stakes the whole time.
None of these were addressed specifically or uniquely to CHLA. Did you forget to include those ones?
Okay? They asked everybody in the country for a spreadsheet. You are ending care. What did you tell them about the spreadsheet? Fuck off? Sure thing?
The memo tells them to use the federal FGC statute for criminal prosecution, which is not remotely applicable. Holy fuck your attorneys suck shit. What claims have you made about GAC that you are worried are false? Have you been investigated? No. You have not been. What is the anti-trans tipline going to do to you? The fuck?
So what? When the Journal of Bleach Enthusiasts publishes a review saying antibiotics are bad but bleach is good, do you stop providing antibiotics? Who gives a shit.
Wow, this is totally different from February, when they definitely weren’t doing that with all their executive orders already. Totally different landscape now. Hadn’t considered that. You’re so right.
Okay? What about kicking trans people out of your hospital stops CMS from doing that? Anything? How’s Harvard doing these days?
Well, not trans ones I guess.
How much do you spend on trans people a year. Just wondering.
And when you stop writing trans people’s prescriptions they’ll run out after 30 days.
Brother you should look up the stats on trans people sometimes if this is what you care about.
No, you have a responsibility to first, do no harm, not a responsibility to be the bad guys in first, they came for.
This is backwards. It’s a challenge to your organization and a significant change to your mission, vision and values.
Not that deeply held, then.
Go fuck yourselves.