Transgender Floridians scrambling as Medicaid coverage ban begins

In hindsight, August Dekker's surgery came just in time.

Dekker, 28, came out as a transgender man in 2015 and started hormone replacement therapy two years later. In April, he underwent a bilateral mastectomy. The procedure is a treatment option for people who experience gender dysphoria, or the distress one feels when their gender identity doesn't align with their sex assigned at birth.

His surgery and hormones were covered by Medicaid, a health insurance program for low-income Americans. Without it, he said, the surgery would have cost about $13,000 — a financial impossibility for Dekker, of Spring Hill, who is unable to work because he has rheumatoid arthritis. His only source of income is a Supplemental Security Income payment of $841 a month.

The treatment gives him "the ability to not hate myself," he said, "and to live a comfortable life ... Hormone replacement therapy is life-saving medication for trans people, and surgery can be a life-saving procedure as well."

But, beginning Sunday,, Florida Medicaid is set to end coverage of gender dysphoria treatment, leaving Floridians like Dekker in limbo about how they'll afford treatment on their own.

"It's targeting the poorest folks in our state who have the least access to resources," said Simone Chriss, director of the Transgender Rights Initiative at Southern Legal Counsel, a nonprofit public interest law firm. "It's incredibly insidious."

Chriss' group is working with the LGBTQ rights organization Lambda Legal and the Florida Health Justice Project to pursue potential challenges to the rule, including a possible lawsuit. Lambda Legal has successfully challenged similar exclusions in West Virginia and Alaska, said Carl Charles, a senior attorney in the group's Southern Regional Office. Florida joins eight other states with Medicaid exclusions, Charles said.

A spokesman for the Agency for Health Care Administration, which oversees Florida's Medicaid program, said the agency is "prepared to defend the integrity of our well-established rule-making process."

"The Agency will not comment further beyond stating that these attacks are clearly coming from unscientific and partisan-motivated organizations posturing for a lawsuit against the rule," Communications Director Brock Juarez said.

The new policy comes two weeks after the Florida Board of Medicine voted to begin the rule-making process to potentially ban gender-affirming care for all children and impose an abortion-style waiting period for adults seeking such treatment.

Along with the Medicaid exclusion, the potential restrictions have created a one-two punch for transgender Floridians in what has already been a discouraging couple years for LGBTQ people and their allies.

Last year, Florida passed a law banning transgender girls and women from participating in female sports, and this year Gov. Ron DeSantis signed a bill restricting how and when schools can discuss gender identity and sexual orientation.

"I don't think I can remember a time when I could turn on the TV and see my existence be debated ... I feel like the world is on fire," said Nikole Parker, who is transgender and works as the director of transgender equality for the LGBTQ rights group Equality Florida.

"We're just human beings trying to live like anyone else and trying to access health care like anyone else," she said, "and just because the trans experience isn't widely understood doesn't make it anything bad. It's just different."

The controversy around gender-affirming care in Florida began in April, when the Florida Department of Health issued guidance questioning the efficacy of such care for children and teens. The same day, AHCA Secretary Simone Marstiller directed her agency to look into whether gender dysphoria treatments are consistent with medical standards.

The agency issued a report in June that said there was little evidence to show that hormone replacement therapy, puberty blockers and gender-confirmation surgery are effective treatments for gender dysphoria and that such treatments may cause harmful long-term effects.

In July, dozens of people jammed a Tallahassee auditorium to express their opposition and support for denying Medicaid treatment. The AHCA panel heard religious, political and medical arguments for and against the proposal.

Both the Department of Health guidance and the AHCA report garnered significant pushback from the medical community.

In April, more than 300 health care providers published a letter in the Tampa Bay Times that said the Department of Health guidance "misrepresents the weight of the evidence, does not allow for personalized patient and family-centered care, and would, if followed, lead to higher rates of youth depression and suicidality." The letter notes that major medical associations including the American Academy of Pediatrics and the Endocrine Society support gender-affirming care for youth.

Then, a group of mostly Yale University professors published a paper criticizing the AHCA report as "not a serious scientific analysis but, rather, a document crafted to serve a political agenda."

"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," said the review, which was issued in July. "The report makes false statements and contains glaring errors regarding science, statistical methods, and medicine."

Much of the criticism of transgender health care centers around children — an age group the DeSantis administration views as needing special state protection.

DeSantis on Twitter called gender-affirming care "a euphemism for disfiguring kids," and groups such as Moms for Liberty, which has an influential foothold in Florida, have advanced debunked beliefs that children grow out of being trans.

However, the Medicaid rule affects recipients of all ages. A report from the Williams Institute at UCLA estimated that 9,000 transgender adults were enrolled in Medicaid in Florida. It didn't include an estimate for the number of children.

Charles, the Lambda Legal attorney, warned that recipients who can no longer afford gender-affirming care will start to see a resurgence of depression, anxiety and other negative effects of gender dysphoria.

"People are really scared," he said. "Having that care ripped out from underneath them is going to be particularly debilitating."

That's Dekker's biggest concern. If he struggles to afford the $60 a month out-of-pocket cost for testosterone, he has family members who could step in and help. He's more worried for people without that lifeline, he said. He also knows of Medicaid recipients who were in the process of obtaining coverage for top surgery who are now "scrambling for a way to pay out of pocket," he said.

Soon after his own surgery, Dekker went to Honeymoon Island State Park off the coast of Dunedin with some friends for his birthday. It was the first time he'd ever been shirtless in public.

"It was an afternoon full of joy and laughter," he said. "I've never felt more euphoric about my body than in that moment."