Federal judge strikes down Florida ban on using Medicaid funds to treat gender dysphoria

A federal judge struck down Florida rules that sought to prevent Medicaid from paying for certain treatments for gender dysphoria, in a challenge to the administration of Republican Gov. Ron DeSantis.

In a strongly worded ruling issued Wednesday, U.S. District Judge Robert Hinkle said a Florida rule and statute that banned most Medicaid payments for puberty blockers, hormonal treatments and surgeries were adopted “for political reasons,” following what he called a “biased” process that went against scientific evidence. The American Psychiatric Association defines gender dysphoria as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.”

The Florida Agency for Health Care Administration had moved to ban the state’s Medicaid program from paying for gender-affirming care after a report it requested called those treatments “experimental and investigational.”

The judge said the rules violated the Medicaid Act, as well as the constitutional right to equal protection under the 14th Amendment and the prohibition of sex discrimination under the Affordable Care Act.

“Gender identity is real. The record makes this clear,” said Hinkle, who was appointed by President Bill Clinton (D) to the court in 1996.

Earlier this month, the same judge issued a preliminary ruling allowing three transgender minors in Florida to continue receiving treatment with puberty blockers and cross-sex hormones despite a law signed by DeSantis last month that banned gender-affirming medical care for minors. Hinkle said he relied on the evidence in that ruling to issue his latest ruling. “Same record, same findings and conclusions,” Hinkle said.

DeSantis’s office did not immediately respond to an overnight request for comment.

The Wednesday ruling comes as more Republican-led states have in recent years moved to restrict or ban gender-affirming care. While these efforts previously focused more on minors, recent bills in states such as Tennessee and South Carolina have proposed restrictions, including on state funding for gender-affirming care, that would also affect adults.

Florida moved to challenge the use of public funds for gender-affirming care in 2022. Simone Marstiller, the DeSantis-appointed secretary of the Florida AHCA at the time, ordered a review of Medicaid coverage for the treatment of gender dysphoria.

The report concluded that there was insufficient evidence that puberty blockers, cross-sex hormones and surgery are safe and effective treatments for gender dysphoria. “These treatments do not conform to GAPMS and are experimental and investigational,” it said, using an acronym for “Generally Accepted Professional Medical Standards.”

The judge said the order to prepare a report for a treatment that had already been approved for Medicaid coverage was contrary to usual practice. He said the AHCA hired consultants to put together the report, even though these kinds of reports are usually compiled internally. He also accused the AHCA of retaining the “only consultants known in advance for their staunch opposition to gender-affirming care.”

After the report came out, the AHCA proposed and later adopted a rule preventing Medicaid from paying for these treatments. The judge said the agency “conducted a well-choreographed public hearing that was an effort not to gather facts but to support the predetermined outcome.”

The lawsuit that sparked the judge’s ruling was filed by two transgender adults and the families of two transgender minors against the AHCA and its current secretary, Jason Weida, also appointed by DeSantis. The plaintiffs challenged the new rule and a statute enacted later by the Florida legislature that banned the use of state funds, including Medicaid funds, for “sex reassignment prescriptions or procedures.”

In their original complaint, the plaintiffs said that “thousands of Floridians” would be denied “medically necessary care” because they could not afford to pay for the care without Medicaid reimbursement.

Hinkle on Wednesday ruled that the Florida rule and statute were “invalid to the extent they categorically ban Medicaid payment for puberty blockers and cross-sex hormones for the treatment of gender dysphoria.” He said there was no “legitimate state interest” in banning public payments for either treatment. However, he ruled against a plaintiff’s retrospective claim for nominal damages related to a mastectomy for which the plaintiff was denied Medicaid coverage but eventually self-funded.

The judge ordered Weida and the AHCA to “approve Medicaid payment for services rendered from this date forward for the evaluation, diagnosis, and treatment” of the four plaintiffs. He also said they “must not take any steps to prevent the administration of cross-sex hormones” to the adult plaintiffs, and of puberty blockers or cross-sex hormones to the underage plaintiffs.

After the ruling, one of the plaintiffs, August Dekker, 29, a transgender man from west-central Florida, said he was “extremely relieved” that he wouldn’t “have to worry” about paying for his medical care.

“Florida’s policy effectively denied me the treatment my doctors recommended, because as a low-income Floridian with disabilities, I rely on Medicaid to afford my health care. I am also happy for other transgender Floridians that get care through Medicaid, as now access to that lifesaving, critical care can continue,” Dekker said.

Omar Gonzalez-Pagan, counsel for Lambda Legal, one of the groups that filed the lawsuit on behalf of the plaintiffs, praised the court for responding to “facts and the law, not fearmongering and heated rhetoric.”

“We are gratified by today’s result which protects access to care for some of the most vulnerable Floridians, transgender Medicaid beneficiaries,” Gonzalez-Pagan said in a statement, adding that “today’s ruling makes clear that discrimination is wrong and recognizes that every person in Florida, including transgender people, deserves equal access to evidence-based and lifesaving medical care.”