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Objectives: Historical and ongoing colonial violence, racism, discrimination, criminalization, and intergenerational trauma continues to impact the health of Indigenous women (cisgender and transgender) and Two-Spirit Peoples. Previous and ongoing work clearly articulate the deeply harmful roles of colonialism and racism in continuing to systemically exclude Indigenous Peoples from accessing equitable and culturally safe healthcare. While the COVID-19 pandemic has amplified structural inequities, little attention has been paid to how the pandemic impacts healthcare access for Indigenous women and Two-Spirit Peoples living in urban settings. The aim of this study was to evaluate factors associated with experiencing difficulty accessing routine healthcare in a cohort of marginalized urban Indigenous women and Two-Spirit Peoples on the ancestral, occupied territories of the Musqueam, Squamish and Tsleil-Waututh Nations in what is now referred to as Metro Vancouver, Canada during the COVID-19 pandemic. Methods: Data were drawn from AMPLIFY, a study of Indigenous cis and trans women and Two-Spirit Peoples in Metro Vancouver. Analyses drew on baseline and semi-annual questionnaire data collected with sex workers and women living with HIV from October 2020–August 2021. We used bivariate and multivariable logistic regression with generalized estimating equations (GEE) to model correlates of experiencing difficulty accessing a family doctor, nurse, or clinic for routine healthcare during the COVID-19 pandemic in the last 6-months. Results: Amongst 142 marginalized Indigenous women and Two-Spirit Peoples (199 observations), 27.5% reported difficulty accessing routine healthcare. In multivariable GEE logistic regression, participants who had ever been pregnant (AOR:4.71, 95% CI:1.33–16.66) experienced negative changes in psychological and emotional well-being (AOR: 3.99, 95% CI: 1.33–11.98), lacked access to culturally safe health services (AOR:4.67, 95% CI:1.43–15.25), and had concerns regarding safety or violence in their community (AOR:2.72, 95% CI:1.06–6.94) had higher odds of experiencing recent difficulty accessing routine healthcare. Discussion: Findings are in line with the BC Commissioned In Plain Sight report which recommends the need for accessible, culturally safe, anti-racist, and trauma-informed routine healthcare for marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples during the current and future pandemics. More community-based research is needed to understand access needs for culturally safe routine healthcare amongst marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples.