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Under current rules, you don't need a referral because we have informed consent. So long as you pass a medical check, you can accept responsibility for the effects and start HRT, with no psychological gatekeeping or dysphoria diagnosis. Like I said, places like Planned Parenthood can get you a prescription for a few hundred dollars out of pocket, which is less expensive than jumping through insurance hoops in the long run (I say from firsthand experience)

A ton of progress has been made in the American psychology community, especially compared to places like the UK. Gender affirmation is fairly accepted as the only evidence based method to handle trans patients, at least by academic consensus. Even the trans medicalists here have a hard time denying that we exist and are best helped by affirmation. The data doesn't support any other treatment being anywhere near as effective. It's probably one of THE MOST effective treatments for any psychological issue.

The biggest issue is that the new fascist government will illegally force the psychology community's hand without approval from congress. There will be fierce resistance in academia, but the government will use economic coercion and override the science in the law. However, this will take time, and you will be safest in blue states. Medical science is in grave danger for trans people, women, and anyone who doesn't fit their mold.

I honestly can't predict all the challenges we'll face, but the economy will also tank, so prepare to work outside official channels to get basic things done.