Federal judge orders Florida Medicaid to cover gender-affirming care
Image via by Lily Fineout

'Gender identity is real.'

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 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 another earlier this month where Hinkle ruled three Florida minors could receive “puberty blockers” and other types of care despite the prohibition in 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 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 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 the DeSantis administration often asserts Florida’s policies on puberty blockers and cross-sex hormones mirror those in Europe, which Hinkle said 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.”

In his ruling, Hinkle orders Agency for Health Care Administration Secretary Jason Weida to pay the care for the four transgender plaintiffs: August Dekker, Brit Rothstein, Susan Doe, and K.F.

Christine Jordan Sexton

Tallahassee-based health care reporter who focuses on health care policy and the politics behind it. Medicaid, health insurance, workers’ compensation, and business and professional regulation are just a few of the things that keep me busy.


  • SteveHC

    June 21, 2023 at 9:38 pm

    ALWAYS heartening to see a judge making a rational courtroom decision based on objective facts rather than mere opinion, political or religious ideology.

  • Michael K

    June 21, 2023 at 9:46 pm

    “Hinkle said the 2022 report was “from the outset, a biased effort to justify a predetermined outcome, not a fair analysis of the evidence.”

    So much of the DeSantis radical agenda is based on a campaign slogan, not sound public policy, fairness, decency or compassion.

  • Earl Pitts American

    June 21, 2023 at 9:47 pm

    Good evening America,
    Everybody just relax. Its just Old Lefty and ready to retire judge Hinkle. His rullings are virtually meaningless other than being a pit stop to a higher court to have Hinkles order reversed.
    Dont any lefties get too happy over Hinkle’s temporary order and spend a bunch of money partying too hard now.
    Thank you America,
    Earl Pitts American

    • Elliott Offen

      June 22, 2023 at 7:31 am

      Kavanaugh and Barrett’s opinions are meaningless because they lied to get confirmed. They are illegitimate, and YOU are illegitimate because of your many mental health problems.. bipolar mania, intellectual disability (tropical 2 ocean tornado), borderline schizophrenia, and your narcissistic personality. You need medication and inpatient treatment.

    • Kr is Read

      June 23, 2023 at 11:48 am

      Perhaps you would like to explain why a Trump appointed judge in Indiana just blocked their ban on pretty much the same terms?

  • PeterH

    June 21, 2023 at 10:21 pm

    Reversing Republican policies in every State will be time consuming and expensive.

    Republicans are America’s biggest problem!

    Vote Republicans out of office!

    • dave boss10

      June 22, 2023 at 1:19 am


  • dave bossio

    June 22, 2023 at 1:20 am


  • JEnnifer

    June 22, 2023 at 6:46 am


  • Tom

    June 22, 2023 at 8:31 am

    Seems most of his attempts at passing laws fail. He may have gone to his fancy pants colleges but it would seem that he didn’t pay much attention. I guess he was busy avoiding all the woke folks who were chasing him around giving him wedgies.

  • Kendra

    June 22, 2023 at 10:43 am

    Hinkle keep iterating that “gender identity is real,” which is legally irrelevant to any of these cases. It’s an activists talking point, and it’s really weird that he keeps saying it. Gender identity is not what is at issue here.

    What is at issue is treatment for *gender dysphoria* — and the state never argued that GD doesn’t exist. These cases are about whether the treatments 1.) can be constitutionally prohibited by the state (probably not since this implicates constitutional rights and there are less restrictive alternatives to total bans) and 2. whether the state can refuse to use Medicaid funds to cover the treatment (almost certainly, since these are not FDA approved treatments and are based on sparse and very low-quality evidence for now).

    To be clear, though, kids aren’t treated for ‘gender identity.’ The was the whole point of creating the GD diagnosis in the DSM 5: to depathologize trans identity and make it clear that the condition to be treated is not the identity itself, but the potential dysphoria associated with it.

    I also find it odd that this ruling was based on rational basis review; I don’t see how this survives appeal. Does the judge really expect the appellate court and general public to believe there is NO conceivable rational basis for not using state funds to pay for non-FDA approved treatments that, when used as directed by WPATH guidelines, results in permanent sterilization of the child? Come on. That’s silly.

    Of COURSE the state can assert a rational basis for not paying to sterilize children or drastically alter their endocrine systems as a form of mental health treatment. We don’t even know the potential costs of complications of these treatments down the road, but there are likely to be significant iatrogenic costs associated with it down the line.

    In light of the myriad countries in Europe finding precisely the opposite of Judge Hinkle after systematic reviews (no longer administering blockers and CSH unless part of a clinical research trial) this ruling is extreme to the point of absurdity. The systematic reviews explicitly found that, as of now, there’s no quality evidence that the benefits outweigh the harms. That might not justify a total ban, but it certainly gives the state a reason not to pick up the tab.

    • Kristine Read

      June 23, 2023 at 11:53 am

      What he said is that none of the European countries have passed a total ban. That is fact. This care is available in every one of those states still, under similar circumstances.

      Also his reference to Gender Identity is real is because the state did not dispute this. And the states own witness stated that this care can be medically necessary, and should not be completely banned.

      • Kendra

        June 23, 2023 at 12:29 pm

        While no European countries have passed a ‘total ban,’ they have restricted it enormously and only allow it under very specific research protocols. They have also conducted systematic reviews that found quite explicitly that the benefits don’t outweigh the harms.

        It is unequivocally false to claim that states in the US provide care under “similar circumstances.” The overwhelmingly majority of such care is NOT done under the auspices of any sort of research trial. In fact, that is one of the problems: the WPATH standards are totally discretionary (Karasic himself published a study in 2017 finding that 55% of WPATH surgeons did not follow WPATH guidelines and performed vaginoplasties on minors) and most of these clinics are not keeping records or conducting appropriate follow ups of those who discontinue care.

        That’s not to mention the profit motive in the US system.

        The state *can’t* “dispute” the concept of “gender identity” because it’s totally unfalsifiable and not subject to any objective standard or testing. It is based entirely on self-report. I don’t know what it means ontologically to claim that it’s “real,” and neither does the judge.

        There was no evidence adduced as to whether ‘gender identity’ is ‘real’ because no such evidence can exist in theory. The plaintiffs even asserted in their pleadings that “Everyone has a gender identity,” which is frankly a religious claim rather than a scientific one, and totally irrelevant to the issues in the case.

        Doctors don’t ‘diagnose’ gender identity, there is no test for ‘gender identity,’ and every time academics try to publish research on potential biological causes (which might lead to objective testing!), activists manage to get the paper pulled before publication. Because any objective test for gender identity is considered improper ‘gatekeeping’.

    • Earl Pitts American

      June 25, 2023 at 3:06 pm

      Yes Kendra,
      Hinkle is ready to be put out to pasture.
      Sad part is the Dook 4 Brains Lefty’s, which he always inapproperaly rulled in their favor, none to a person, ever gave a $hlt about Hinkle or ever will. What a life of great potential thrown away by Hinkle.

  • Kendra

    June 22, 2023 at 10:59 am

    This part is pretty extraordinary: “One doubts these treatments are available in Iran…”

    Iran is one of the world leaders in sex reassignment. That is because they forcibly reassign gay people.

    What an embarrassing mistake for the court to make.

  • Linwood Wright

    June 25, 2023 at 9:31 pm

    Another L for DeSatan.

Comments are closed.


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