Lawsuit Suggests Zealotry Disguised as Medicine Led to Denial of Medicaid Coverage for Trans Treatments

A lawsuit to reinstate Medicaid benefits for gender-affirming care has painted a picture of an allegedly hollow and unqualified medical review used by the Florida Agency for Health Care Administration (AHCA) to justify stripping coverage for transgender patients' treatments.

The legal action filed last week claims AHCA's decision to deny Medicaid coverage for gender-affirming care was based on opinions from biased doctors, some of whom appear to have been driven by religious beliefs and were hand-picked by AHCA to support the agency and Gov. Ron DeSantis' agenda.

Among the doctors enlisted by AHCA was Andre Van Mol, according to the court documents. As noted in the lawsuit, Van Mol is a board member of the religious group Moral Revolution, which believes the "normalization of same-sex sexual behavior" reflects society's abandonment of "God's image." The group also claims people are not born gay or transgender but are conditioned to be as such because "they were born human into a fallen world."

On June 2, AHCA and its secretary, DeSantis-appointed Simone Marstiller, revealed the plan to bar Medicaid coverage for gender-affirming care. The agency released a study that said evidence for the efficacy of gender-affirming care is weak, a stance that contradicts consensus among prominent U.S. medical organizations.

AHCA's deputy secretary of Medicaid, Tom Wallace, signed off on the report, which claimed that gender-affirming treatments "exacerbate or fail to alleviate existing mental health conditions and cause infertility and sterility."

Gender-affirming care includes hormone therapy, gender assignment surgery, and puberty blocking drugs.

The AHCA study was challenged by experts from the Yale School of Medicine as well as the University of Texas Southwestern, who found that the agency “makes unfounded criticisms of robust and well-regarded clinical research and instead cites sources with little or no scientific merit.” The American Academy of Pediatrics and the Endocrine Society were among the medical organizations that came out in opposition to the new Florida Medicaid policy.

"In light of the evidence supporting the connection between lack of access to gender-affirming care and lifetime suicide risk, banning such care can put patients’ lives at risk," the Endocrine Society said.

The named plaintiffs in the lawsuit (embedded at the end of the article) are August Dekker, a 28-year-old trans man, and Brit Rothstein, a 20-year-old trans man who resides in Broward county. Represented by their guardians, two plaintiffs are unnamed in the complaint because they are minors: a 12-year-old trans girl who resides in Brevard County and a trans boy.

Each of the plaintiffs has been diagnosed with a condition for which their doctors deemed gender-affirming care to be medically necessary.

"It has been extremely stressful to have to worry about whether I will be able to get the medical care that I need and which is recommended by my doctors. This new Medicaid rule denies me the ability to access treatment that I cannot otherwise afford," Dekker said in a press release. "It’s truly awful and unfair to feel like the state is targeting your existence."

The Florida Medicaid rule denying coverage for gender-affirming care went into effect August 21. Equality Florida has estimated that as many as 9,000 transgender Floridians have been affected.

On September 12, the plaintiffs filed a request for a preliminary injunction to block the regulation. 

When laying out its rational for denying coverage, AHCA cited assessments that were not peer-reviewed, including one by plastic surgeon and Alabama church deacon Patrick Lappert.

Lappert wrote in his assessment that "the medical necessity of transgender chest surgery is not supported by scientific evidence and appears to be firmly in the category of cosmetic surgery." He said available studies on the matter don't methodically analyze depression and suicide risk among transgender patients who undergo gender assignment surgery.

According to the plaintiffs, Lappert went beyond his area of expertise in his assessment. The lawsuit points to a North Carolina federal case in which Lappert's opinions about clinical studies were excluded.

"[Lappert] is not a statistician or epidemiologist, and there is no evidence in his report or deposition that he has any experience, specialized training, or knowledge about crafting a research study, analyzing data, or conducting a clinical trial," U.S. District Judge Loretta Biggs wrote in the North Carolina case, in which coverage of gender-affirming care by a state health plan was at stake.

For its review of pediatric gender-affirming care, AHCA relied on the opinion of Quentin Van Meter, among others. A pediatric endocrinologist and professor at Emory University, Van Meter claimed in his assessment that the recent rise in gender dysphoria diagnoses can be attributed to "online recruiting and grooming of vulnerable children and adolescents by a generously funded political movement aimed at dissolving the reality and birthright of biologic sex."

Medical organizations that support gender-affirming care say diagnoses have increased in recent years because of better understanding and acknowledgement of gender dysphoria, a condition marked by a feeling that one's gender identity does not match their biological sex. The "grooming" terminology mentioned by Van Meter is commonly used by conservative pundits to falsely associate gay and transgender causes with child abuse.

As noted in the lawsuit, Van Meter is the president of the American College of Pediatricians, a conservative political group which opposes marriage equality. The group's website makes the bogus claim that gay marriage is harmful to children.

When New Times reached out for a response to criticism of its report, the Agency for Healthcare Administration said it does not comment on pending litigation.

Filed in the Northern District of Florida, the lawsuit alleges that the axing of Medicaid coverage for gender-affirming care violates transgender patients' constitutional rights under the Fourteenth Amendment. The case includes claims of discrimination under the Affordable Care Act, noting that hormone therapies are “routinely covered by Medicaid when they are for medically necessary purposes other than the treatment of gender dysphoria.”

Additional counts claim AHCA's policy violates federal Medicaid law. As is the case with other states, Florida's Medicaid program is funded in large part by the federal government and must comply with federal law.

The Southern Legal Counsel, Florida Health Justice Project, Lambda Legal, National Health Law Program, and the law firm of Pillsbury Winthrop are representing the plaintiffs. Similar lawsuits in West Virginia and Georgia have succeeded in overturning state rules that blocked Medicaid coverage for transgender patients.

“What AHCA has done by forcing through this rule is cruel, it is unlawful, and it will be remembered as a stain on Florida’s history. We will fight to ensure all Floridians, regardless of income, have equal access to medically necessary healthcare," Simone Chriss, director of the Transgender Rights Initiative at the Southern Legal Council, tells New Times.

According to the Movement Advancement Project, Florida is among nine states that have regulations on the books barring Medicaid coverage for gender-affirming care. The Florida Board of Medicine, meanwhile, is considering rules that could outright ban hormone-replacement therapy, puberty blocking drugs, and gender assignment surgery in minors.

Deputy director of Transinclusive Group, Nic Zantop, tells New Times that "discrimination against trans and LGBTQ+ people is already widespread, and forcing people who are already systemically marginalized to now have to fight for healthcare access is cruelty in action.”