The U.S. Supreme Court on Tuesday is scheduled to hear oral arguments in a case that could impact state laws around the country that ban “conversion therapy,” a controversial counseling practice for LGBTQ+ youth. (Photo by Anna Moneymaker/Getty Images)

The U.S. Supreme Court on Tuesday is scheduled to hear oral arguments in a case that could reverse or solidify state laws across the country that ban a controversial counseling practice for LGBTQ+ youth.

The case challenges a 2019 Colorado law that bans “conversion therapy” for children and teens. Conversion therapy is a catchall term for efforts to change the sexual orientation or gender identity of LGBTQ+ people. Sometimes called “reparative therapy,” it can range from talk therapy and religious counseling to electrical shocks, pain-inducing aversion therapy and physical isolation. The therapy has been widely discredited by medical groups.

More than half of states — including some led by Republicans — have banned or restricted the practice for children and teens since California became the first to do so in 2012, according to the Movement Advancement Project, a left-leaning nonprofit research organization that tracks LGBTQ+-related laws and policies.

In recent years, however, Republicans in several states have worked to reverse bans, with some success. A poll in June by Data for Progress, a liberal think tank, found that although less than half of Republican voters, 43%, support or strongly support conversion therapy, more than half — 56% — said the Supreme Court ought to allow states to ban it.

A decision in the Colorado case, expected next year, could have far-reaching ramifications for dozens of other states.

“I think we’re all really worried about the implications,” said Cliff Rosky, a professor of law at the University of Utah. Rosky helped draft Utah’s 2023 law prohibiting licensed professionals from practicing conversion therapy on LGBTQ+ youth. That measure unanimously passed the Republican-controlled legislature.

“We certainly hope the court will uphold the right of states to regulate the behavior of therapists that it licenses and protect children from a lethal public health threat,” he told Stateline.

The impact on other states’ laws would depend on the scope of the high court’s ruling. But most of those laws are similar to Colorado’s, Rosky said.

“Certainly, a broad ruling against Colorado’s law would jeopardize the constitutionality of all the other laws.”

In Chiles v. Salazar, a licensed counselor in Colorado Springs, Kaley Chiles, sued state officials in 2022 over a law that bars licensed mental health professionals from conducting conversion therapy on clients under 18. She argues the law violates her First Amendment right to free speech and interferes with her ability to practice counseling in a way that aligns with her religious convictions. Chiles is represented by conservative religious law firm Alliance Defending Freedom.

“The government has no business censoring private conversations between clients and counselors,” Jim Campbell, chief legal counsel for Alliance Defending Freedom, said in a news release when the group filed its opening brief in June. “Colorado’s law harms these young people by depriving them of caring and compassionate conversations with a counselor who helps them pursue the goals they desire.”

Colorado Attorney General Phil Weiser, a Democrat, said in an August news conference that the law doesn’t prohibit a provider from sharing information or viewpoints with a patient, and that therapists are still allowed to talk with patients about conversion practices offered by religious groups.

But he called conversion therapy a “substandard, discredited practice.” Conversion therapy has been denounced by major medical organizations including the American Medical Association, the American Psychological Association, the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

“This practice has been used in the past to try to force patients to change their sexual orientation or their gender identity,” Weiser said. “The science, however, says that this practice is harmful. It doesn’t work.

“Regardless of how it’s performed, there can be real harms from this practice. And those harms can include depression, self-hatred, loss of faith, even suicide.”

The key question in the case is whether Colorado’s law regulates professional standards of conduct and speech, or whether it attempts to regulate the right to free speech, said Marie-Amélie George, a legal historian who has published extensively on LGBTQ+ rights and is a professor of law at Wake Forest University School of Law.

“What is really interesting about these laws is that most licensed health professionals don’t offer conversion therapy because professional associations across the board have condemned it as extremely harmful,” George told Stateline. After the mainstream mental health community disavowed efforts to change people’s sexual orientation by the late 1980s, conversion therapy “became primarily the province of religious and lay ministers,” she said.

State laws like Colorado’s don’t restrict clergy and lay ministers from engaging in conversion therapy, she said. They address only the small subset of state-licensed mental health professionals who wish to use it.

In August, attorneys general in 20 states and the District of Columbia filed an amicus brief supporting Colorado’s law. They argue the First Amendment doesn’t shield mental health practices from regulation when the state deems them dangerous or ineffective, and that states have a long and established history of regulating professional standards of care.

Colorado isn’t the only recent battleground over conversion therapy, as conservative majorities in the courts, state legislatures and at the federal level have opened the door for Republican lawmakers and conservative Christian groups to reinstate the practice.

Earlier this year, Kentucky’s Republican-controlled legislature passed a bill canceling Democratic Gov. Andy Beshear’s 2024 executive order that banned conversion therapy for minors. Beshear promptly vetoed the bill, but the legislature overrode his veto in March.

In April, a coalition of Republican attorneys general from 11 states, led by Iowa and South Carolina, appealed a January decision by a U.S. district court judge to uphold a 2023 Michigan law that’s similar to Colorado’s. It prohibits mental health professionals from trying to alter a minor’s sexual orientation or gender identity. The case began when Catholic Charities of three Michigan counties filed a lawsuit targeting Michigan’s law in 2024 on behalf of a licensed therapist.

In July, a Virginia court partially struck down the state’s 2020 ban on conversion therapy for minors. Republican lawmakers in Michigan introduced a bill in July to repeal their state’s ban, while Missouri’s Republican attorney general sued to overturn local conversion therapy bans.

From the mid-1990s until the mid-2010s, LGBTQ+ rights advocates won a lot of cases before the U.S. Supreme Court, said George, the Wake Forest professor.

“But in the years since, the Supreme Court has been more hostile to LGBTQ+ rights claims,” she said. “I think, with the political environment of the court, it will be interesting to see what they do given how they have treated other LGBTQ+ rights cases in recent years.

“States are extremely similar in the laws they have enacted, so the decision in this case will probably affect all of the conversion therapy bans in this country.”

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

A 10-week-old infant drinks from a bottle. A new study found that when rural hospitals were acquired by larger health systems, they were 30% less likely to still offer labor and delivery services five years later. (Photo by John Moore/Getty Images)

Rural hospitals are less likely to offer obstetric services after they’ve been acquired by a larger health system, leading to mixed outcomes for mothers and babies, according to new research.

It’s part of an accelerating trend that’s reshaped how Americans get health care: Larger health systems gobble up smaller facilities in a bid for financial stability.

“The hospital industry has undergone tremendous transformation over the past few decades, with nearly 1,600 mergers between 1998 and 2021,” said Martin Gaynor, a coauthor of the study and emeritus professor of economics and public policy at Carnegie Mellon, in a statement.

Those large-scale changes to the health system can affect costs, quality and access to care, he said.

Over the past five years, more than 100 rural hospitals have stopped delivering babies or announced they’ll stop in 2025, according to the most recent data from the Center for Healthcare Quality & Payment Reform. Less than half of rural hospitals still offer labor and delivery services.

Gaynor and a team of researchers from Carnegie Mellon, Northwestern University and the University of Georgia examined how hospital mergers have affected access to obstetric care in rural areas, and the quality of that care. They found that rural hospitals were part of more than 450 mergers from 2006-2019.

Once those rural hospitals were acquired by larger systems, they were 30% less likely to still offer labor and delivery services five years later. Many of the shuttered obstetric departments were the sole local source of obstetric care.

That loss translated to fewer resources — such as practicing OB-GYNs — in the county where the acquired hospital was located, researchers found.

The number of births in those counties didn’t change; families just had to go elsewhere for care.

Less access to nearby care could explain those counties’ small increases in health problems among women during or after pregnancy and child birth, and higher rates of smoking among pregnant women, researchers said.

On the flip side, they found that some patients went to higher-quality facilities farther away. And in rural hospitals that didn’t close their obstetric departments following a merger, the quality of care tended to rise.

In recent years, officials in dozens of states have championed laws to increase oversight of mergers and other health care dealmaking.

In the wake of devastating hospital closures tied to corporate financial maneuvering, some states have strengthened their antitrust laws.

Last year alone, 22 states enacted at least 34 laws related to health system consolidation and competition, according to the National Conference of State Legislatures, an advisory think tank for lawmakers. Other states, meanwhile, have paved the way for health mergers in a bid to save failing rural hospitals.

At least 35 states now require hospitals, health systems, providers and private equity firms to notify a state official of proposed mergers or other contracts.

Earlier this month, California lawmakers passed a bill to expand the state’s authority in overseeing mergers and acquisitions in health care. It’s headed to Democratic Gov. Gavin Newsom’s desk, though Newsom vetoed a similar measure last year.

At the federal level, President Donald Trump’s administration has not signaled an interest in increasing antitrust oversight. But Trump’s recent tax and spending law did include $50 billion in funding over the next decade aimed at helping states strengthen rural health care. Massive cuts to Medicaid also in the law could have devastating impacts on rural hospitals struggling to stay afloat, however.

The Centers for Medicare & Medicaid Services this week announced that states have until Nov. 5 to apply for rural health funding. States must show that they’ll use the federal dollars in a way that aligns with certain CMS goals, including helping improve access to care and strengthening retention of health care workers.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.