Florida to bar Medicaid coverage for those seeking gender-affirming care

ROCKLEDGE, UNITED STATES - 2022/08/03: Florida Gov. Ron DeSantis at a press conference to announce the expansion of a new, piloted substance abuse and recovery network to disrupt the opioid epidemic, at the Space Coast Health Foundation in Rockledge, Florida. The Coordinated Opioid Recovery (CORE) network of addiction care was piloted in Palm Beach County and will be expanding in up to twelve counties to assist Floridians battling with addiction. (Photo by Paul Hennessy/SOPA Images/LightRocket via Getty Images) (SOPA Images via Getty Images)
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Transgender Floridians of all ages will soon no longer be able to use Medicaid to help pay for gender-affirming care under a new state rule, a move that comes as Gov. Ron DeSantis's administration pursues policies increasing restrictions on medical treatments like puberty blockers and hormone therapy.

Florida joins at least 10 other states - including Arizona, Missouri and Texas - in barring residents from using Medicaid to pay for several often-prescribed medications and surgeries for those diagnosed with gender dysphoria. The rule was published Wednesday and is slated to go into effect Aug. 21.

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Florida's move is a "major change" that is going to disrupt low-income members of the transgender community who have been receiving treatment through Medicaid for years, said Carl Charles, senior attorney of the Southern Regional Office for Lambda Legal, an LGBTQ advocacy group. He said his group was "alarmed" to see the measure come so quickly and that "people would be right to assume" the move has the stamp of approval from DeSantis, who is widely considered a potential 2024 Republican candidate for president.

Brock Juarez, a spokesman for the Florida's Agency for Health Care Administration, told The Washington Post the agency conducted "a very thorough process and our in-depth work and findings really speak for itself."

Lambda Legal is "exploring all options" to challenge the rule, Charles said.

"It's gut-wrenching," he said. "People have made a decision in their lives to pursue a course of care that's going to be life-changing, and now they're facing the potential that they may not be able to move forward with that."

Earlier this year, Florida Surgeon General Joseph Ladapo released a memo to the state's health-care workers advising providers against providing gender-affirming treatments, such as puberty blockers, to minors. The memo also advised against social transition - a nonmedical process in which a person changes their clothing, name or pronouns to better align with their gender identity. Ladapo wrote that this should "not be a treatment option for children or adolescents."

The country's largest medical organizations, including the American Academy of Pediatrics, the Endocrine Society and the American Academy of Child and Adolescent Psychiatry recommend gender-affirming care to help treat minors experiencing gender dysphoria - a condition in which a person experiences psychological distress because their biological sex and gender identity do not align.

Gender-affirming care can, but does not always, include medical interventions like hormone replacement therapy, chest surgery or voice therapy. Among the most common medical treatments for adolescents are puberty blockers, which are reversible. According to current standards, genital surgeries are not recommended for patients under the age of 18. In April, 300 medical providers in the state wrote an open letter in the Tampa Bay Times criticizing the state's guidance against gender-affirming care.

"Florida was really the first state to come for the throat of the medical evidence behind gender-affirming care, to create this false narrative that there is not sufficient evidence to support the benefits," said Meredithe McNamara, an assistant professor at Yale's School of Medicine, who worked with a team of researchers to review Florida's medical report on the issue.

"We are alarmed that Florida's health care agency has adopted a purportedly scientific report that so blatantly violates the basic tenets of scientific inquiry," the researchers wrote.

State medical boards historically have not decided policy or standards of care, McNamara said. Instead, their work tends to focus on issues like licensing or reviewing complaints against physicians. AHCA's Medicaid decision, as well as its impending rule changes, she said, are "really unusual and concerning to the medical community."

In a post-Roe world, "it's kind of terrifying to think about the precedent that this might set," McNamara added.

An estimate from a 2019 study by the Williams Institute at UCLA School of Law showed there were about 9,000 people receiving gender-affirming care each year in Florida. Some research suggests that trans people are more likely to be on Medicaid; one survey reported 15% have a household income of under $10,000 a year, compared to 4% of the general population. As of 2019, approximately 152,000 trans adults are enrolled in Medicaid across the country - and about 32,000 of those lived in states that denied coverage for gender-affirming care, according to the UCLA report.

The move comes at a time when LGBTQ advocates say some of the state's most vulnerable residents are already feeling targeted.

In the last two years, Florida has passed legislation banning trans girls and women from participating on female sports teams in the state's public schools, as well as a law that restricts classroom discussion of gender and sexuality.

Last week, Florida's Board of Medicine voted to begin weighing new restrictions, spurred by pressure from DeSantis and the state's Department of Health, that could ban gender-affirming care for all trans youth, as well as requiring a 24-hour waiting period for adults seeking transition care, such as hormone therapy or surgery.

At a recent news conference, DeSantis said doctors were "literally chopping off the private parts of young kids. And that's wrong." He added that his administration is "doing stuff administratively and with medical licenses," but that Florida lawmakers "may want to come in and do something more significant on that."

Such moves have rallied supporters, including many who showed up to the recent Board of Medicine meeting. WFSU reported a number of the attendees belonged to religious groups. Among them was Jeannette Cooper, co-founder of Parents for Ethical Care, an organization that believes "no child is born in the wrong body." Cooper urged the state to impose a ban on gender-affirming care for trans youth.

"For many children, a trans identity is a crutch," Cooper said. "It is a placeholder for real suffering that hasn't been named."

Alyssa MacKenzie, an Orlando-based trans rights activist, has found Orlando to be, for the most part, safe and affirming for LGBTQ people. But in the past six months, as the governor has prioritized legislation restricting LGBTQ rights and labeled critics "groomers," the 42-year-old advocate has noticed an increase in harassment and attacks, including on children and families.

MacKenzie was particularly alarmed by earlier guidance advising doctors against letting children socially transition - which requires no medical intervention and could be as simple as changing a name or the way one wears their hair. Transgender youth face far higher rates of depression and suicidality than their cisgender peers.

For trans adults and children, accessing gender affirming care and receiving support for their transition is often a matter of "life and death," MacKenzie said. "To forcibly detransition trans youth and take away health care for trans adults is the most serious threat trans people have faced in the United States."

While other states have sought to limit access to gender-affirming care for trans youth, most have sought to do so via state legislatures. But despite Florida lawmakers attempting to pass this legislation in recent years, these bills have not succeeded in the statehouse.

Instead, Florida has sought to bar people from accessing gender-affirming care through its Department of Health - which some health experts have criticized as an example of government overreach that could set a dangerous precedent.

Mike Haller, a professor and chief of pediatric endocrinology at the University of Florida, said the decision to bar people from using Medicaid to cover gender-affirming care was "cruel and unusual punishment" for patients seeking safe, evidence-based care.

The new rule would affect all transgender patients on Medicaid, including adults. Haller, who treats children at his clinic, estimated that 60% to 65% of his patients are on Medicaid.

"It's already had a concerning, chilling effect," Haller said. "[Patients] are not going to come to their appointments because they're afraid that it is already illegal, and it's not."

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