A staggering percentage of transgender Medicaid recipients across the country aren’t guaranteed gender-affirming medical care, putting them out of step with federal guidelines. That is according to a new report released Wednesday by the Williams Institute, UCLA's LGBTQ think tank.

Sixty-nine thousand (about 45%) of the nation’s estimated 152,000 trans Medicaid recipients are living in states that expressly cover transgender people in Medicaid programs, which provides health insurance to low-income adults.

Meanwhile, the Williams Institute estimates that 32,000 (21%) trans people enrolled in the program live in states that outright ban coverage for trans affirming care, and about 51,000 (33%) live in states where laws are murky. This means more than half of the U.S.'s transgender Medicaid users (nearly 55%) aren't able to easily access gender-affirming health care under the program in their home states.

“This patchwork of protections creates uncertainty for transgender people who are enrolled in Medicaid,” said Christy Mallory, the study's coauthor, in a statement. “Absent further policy changes in states that have bans or lack clear language addressing coverage, many transgender people in the U.S. will continue to face obstacles when seeking health care just because of where they live.”

Medicaid is the largest health insurer in the nation. The 2015 National U.S. Transgender Survey found that 13% of trans people in the America were insured through the program.

The Affordable Care Act (ACA) required Medicaid programs to cover gender-affirming health care starting in 2016, but many states have been sluggish to update their policies, leaving them vulnerable to lawsuits. In August, a federal judge overturned Wisconsin’s ban on trans-affirming Medicaid coverage. Iowa is presently engaged in a bitter legal dispute with two transgender Medicaid recipients seeking trans-related medical care despite its ban on coverage.

Twelve states still exclude coverage for trans people under their medicaid programs, while 18 offer it. Another 20 states don’t have policies either way, creating confusion in those states for trans people trying to access affirming care.

Elizabeth Warren at this month's LGBTQ Presidential Town Hall from HRC and CNN.

The topic of expanded health care has become a hot-button issue for 2020 democratic presidential hopefuls courting LGBTQ voters, with the most progressive in the field backing Medicare-for-All plans.

Senators Bernie Sanders and Elizabeth Warren have backed Medicare-for-All in their platforms, while former Vice President Joe Biden has pitched a more moderate public option, allowing Americans to enroll in more affordable public health insurance.

If any Democrat wins the presidency next year, however, they will have to confront a series of rollbacks to transgender health care protections pushed by Trump.

In the last three years, the Trump administration has instituted “conscience protections” that allow health care workers to to turn away transgender patients for religious or moral objections. The administration has also proposed striking down anti-discrimination transgender protections under the ACA.