Federal judge orders Florida Medicaid to cover gender-affirming care

A federal judge has invalidated a rule and law barring Florida from having Medicaid pay for gender-affirming care provided to transgender individuals.

U.S. District Judge Robert Hinkle on Wednesday concluded that the ban on Medicaid payments violated two federal health care laws and the Equal Protection clause of the Constitution.

Hinkle’s ruling is the second in the last 30 days, coming after one earlier this month where Hinkle ruled that three Florida minors could receive “puberty blockers” and other types of care despite the prohibition in a state law and a pair of medical board rules.

Wednesday’s ruling applies to the state’s $38 billion Medicaid program and the roughly 9,000 transgender enrollees in the program.

“Gender identity is real. Those whose gender identity does not match their natal sex often suffer gender dysphoria. The widely accepted standard of care calls for evaluation and treatment by a multidisciplinary team. Proper treatment begins with mental-health therapy and is followed in appropriate cases by GnRH agonists and cross-sex hormones,” Hinkle wrote in his opinion “Florida has adopted a rule and statute that prohibit Medicaid payment for these treatments even when medically appropriate.”

Florida amended its Medicaid rules in 2022 to ban reimbursement for gender-affirming care after then Medicaid Director Tom Wallace released what he called a thorough report of assessments of the benefits of gender-affirming care and subsequently deemed gender-affirming care as experimental. The label precludes Medicaid from reimbursing for health care because the state’s safety net program doesn’t provide coverage for experimental treatments.

Prior to the 2022 report, AHCA had conducted two previous reports on the generally accepted professional medical standards (GAPMS) on gender-affirming care, according to the ruling. Both reports — a 2016 report on puberty blockers for transgender adolescents and a 2017 report on cross-gender hormones — recommended reimbursing for the care. The reports were prepared internally by AHCA staff.

But the 2022 report was conducted at the behest of the Governor’s Office and AHCA for the first time hired outside consultants to conduct it.

Hinkle said the 2022 report was “from the outset, a biased effort to justify a predetermined outcome, not a fair analysis of the evidence. The report concluded that gender-affirming medical care — puberty blockers, cross-sex hormones, and surgery — were not supported by generally accepted medical standards and were instead experimental. The conclusion was not supported by the evidence and was contrary to generally accepted medical standards.”

Hinkle in his ruling noted that the DeSantis administration has accused organized medicine of pursuing “good politics” and not “good policy.” Hinkle likened the argument to the “pot calling the kettle black.” And while the DeSantis administration often asserts Florida’s policies on puberty blockers and cross sex hormones mirror those in Europe, which Hinkle said that is not true.

“The assertion is false. And no matter how many times the defendants say it, it will still be false. No country in Europe — or so far as shown by this record, anywhere in the world — entirely bans these treatments or refuses to pay for them,” Hinkle wrote, citing a June 20, 2023, court opinion in another lawsuit.

“To be sure, there are countries that ban gays and lesbians and probably transgender individuals, too. One doubts these treatments are available in Iran or other similarly repressive regimes. But the treatments are available in appropriate circumstances in all the countries cited by the defendants, including Finland, Sweden, Norway, Great Britain, France, Australia, and New Zealand. Some or all of these insist on appropriate preconditions and allow care only in approved facilities — just as the Endocrine Society and WPATH standards insist on appropriate preconditions, and just as care in the United States is ordinarily provided through capable facilities. Had Florida truly joined the international consensus — making these treatments available in appropriate circumstances or in approved facilities — these plaintiffs would qualify, and this lawsuit would not be necessary.”

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