What we learned in April about the Florida AHCA’s Medicaid transition care exclusion Rule 59G-1.050(7) and subsequent litigation in Dekker v. Weida: Summary


In August 2022, the Florida Agency for Health Care Administration (AHCA) enacted rule 59G-1.050(7) revoking state Medicaid coverage for treatment of gender dysphoria, including puberty blockers, hormone therapy, and gender-affirming surgeries. This rule and the Florida Boards of Medicine’s administrative bans on trans youth care were supported by the AHCA’s June 2 Generally Acceptable Professional Medical Standards determination, which was the product of a highly nonstandard process uniquely involving anti-trans experts from outside the agency. The rule was promptly challenged in a September 2022 suit against AHCA by plaintiffs Dekker et al. (4:22-cv-00325); a preliminary injunction was denied and the challenged exclusion has remained in effect pending trial in May 2023.

“A conclusion in search of an argument”

On Friday, April 28, 2023, the plaintiffs filed their trial brief (Doc. 199) with over 350 attached exhibits containing information about the AHCA’s anti-trans rulemaking process that was not previously known to the public. This evidence confirms early coordination between the office of Governor Ron DeSantis, the Florida Department of Health, and the AHCA at meetings in early April 2022 (Doc. 200-5). AHCA chief litigation counsel Andrew T. Sheeran was even seeking out anti-trans expert witnesses, including Quentin Van Meter (Pl. 337) and anti-gay conversion therapy provider Miriam Grossman (Pl. 274), prior to FLDOH’s April 20, 2022 anti-trans press release. A series of diagrams dated to June 2022 describe a “Gender Dysphoria/Transgender Health Care Policy Pathway” (Plaintiffs’ trial exhibit 296), “Non-Legislative Pathway” (Pl. 295), and “Projected Rulemaking Timeline” (Pl. 294), beginning with state surgeon general Joseph Ladapo’s April anti-trans guidance and ending in June-September 2022 with “Care Effectively Banned”. This indicates that the AHCA had not initiated an open-ended assessment of evidence on certain medical treatments with the possibility that this evidence could be persuasively robust, but rather that this exclusion was already decided at the outset. Jeffrey English, AHCA’s “GAPMS guy”, called the finding “a conclusion in search of an argument” (Doc. 199).

Plaintiffs’ trial exhibit 296. Gender Dysphoria/Transgender Health Care Policy Pathway. APRIL 2022 - Surgeon General Issues Guidance on Gender Dysphoria. APRIL- EARLY JUNE 2022 (SIX WEEKS) - AHCA Secretary Directs Medicaid Dir. to Initiate GAPMS Process. AHCA GAPMS Report Produced. Medicaid Director Transmits Signed Report to AHCA Secretary. FOLLOWING AHCA REPORT - Legislative Proposal Announced. FOLLOWING AHCA REPORT BOARD MEETING SCHEDULE – Rulemaking: Board of Medicine, Board of Osteopathic Medicine, Board of Psychiatry, Board of Psychology. JUNE-SEPTEMBER 2022 (MINIMUM 90-120 DAYS/EXCLUDING RULE CHALLENGES) - AHCA Initiates Rulemaking. AHCA Contract Amendments/Care Effectively Banned.

The task of producing the desired GAPMS outcome was given to Matthew Brackett and Nai Chen of the AHCA’s Canadian Prescription Drug Importation Program (CPDIP) (Doc. 199), rather than Jeffrey English or the usual Medical and Behavioral Health Coverage Policy department that had authored the previous 2016-2017 GAPMS approving coverage of gender-affirming care (Pl. 256). Romina Brignardello-Petersen of the anti-trans group SEGM was told by AHCA chief litigation counsel Andrew Sheeran on April 21 to use SEGM associate Stephen B. Levine’s expert declaration in the case Tingley v. Ferguson as a model for her portion of the GAPMS report (Pl. 275). After being told by AHCA assistant deputy secretary Jason C. Weida to “keep each expert below $35,000 US for budgetary purposes” (Pl. 280), Brignardello-Petersen billed the state $34,800 (Pl. 292A).

Plaintiffs’ trial exhibit 292A. Invoice 1/1. Requisition No. PR12152548. Description. Amount. Consulting: Evidence evaluation (systematic review of the literature to identify and summarize the best available evidence regarding the effects of gender affirming therapies in people with gender dysphoria), April 20 – May 17, 2022, total: 116 hours ($300 USD per hour). Details: Search and selection of reviews, 33 hours, $9900. Reviews appraisal and synthesis, 38 hours, $11400. Preparation of reports, 24 hours, $7200. Meetings, 5 hours, $1500. Search and synthesis of new studies, 16 hours, $4800. Total, $34800 USD.

AHCA chooses a fringe hate group

A leader of the anti-LGBTQ hate group American College of Pediatricians, Andre Van Mol, was paid by the state to provide revisions to AHCA’s 2022 GAPMS draft report in May (Pl. 286B). Members of the American College of Pediatricians (ACPeds) hold a preexisting absolute commitment preventing them from “[s]aying in their professional opinions that these gender intervention procedures are the standard of care, are safe, are beneficial, are not experimental, or should otherwise be recommended”, as declared by ACPeds president Quentin Van Meter in American College of Pediatricians et al. v. Becerra et al. (doc. 15-1, Ex. 1 at 41(m), November 9, 2021).

36. The Hippocratic Oath acknowledges this, in requiring us to “do no harm” to patients, and in specifying such requirements as, “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course,” the Oath requires. The bar on “suggest[ing] such a course” also limits our members’ ability to refer patients for treatments they do not believe are in their patients’ best interests. B. Views on HHS’s gender identity mandate. 37. HHS’s gender identity mandate (under Section 1557 or the 2016 Grants Rule) conflict with our organization’s foundational principles, and the core ethical beliefs of our members. The mandate violates our beliefs by requiring ACPeds’ members to provide gender-transition interventions, treat patients as if their sex is their gender identity and not their actual biological sex, and engage in speech affirming gender identity regardless of the doctors’ medical judgment and religious or ethical objections. 38. ACPeds members are predominately pediatricians and specialists, including but not limited to pediatric surgeons, family medicine physicians and pediatricians who are dual certified in pediatrics and adult internal medicine. 39. Many members have practices that may include adults, such as family medicine or internal medicine practices, or general surgery, and these practitioners object to these procedures for all adults as well as children. 40. ACPeds members thus seek protection from HHS’s gender identity mandates for all aspects of their practices. 41. The HHS gender identity mandate requires ACPeds’ members to engage in various practices to which our members object on medical and ethical grounds, including the following: a. Prescribing puberty blockers off-label from the FDA-approved indication, in order to treat gender dysphoria or for the diagnosis of [Page 7 omitted for length] l. Ending or modifying the policies, procedures, and practices of ACPeds’ members to not refer for, offer, perform, or prescribe these procedures, drugs, and interventions; m. Saying in their professional opinions that these gender intervention procedures are the standard of care, are safe, are beneficial, are not experimental, or should otherwise be recommended; n. Treating patients according to gender identity and not sex; o. Expressing views on gender interventions that they do not share; p. Saying that sex is nonbinary or on a spectrum; q. Using language affirming any self-professed gender identity that does not correspond to biological sex; r. Using patients’ preferred pronouns according to gender identity, rather than using no pronouns or using pronouns based on biological sex; s. Creating medical records and coding patients and services according to gender identity not biological sex; t. Providing to the government assurances of compliance with the gender identity mandate, providing compliance reports, and posting notices of compliance in prominent physical locations; u. Refraining from expressing their medical, ethical, or religious views, options, and opinions to patients when those views disagree with gender identity theory or transitions; and v. Allowing patients to access single-sex programs and facilities, such as mental health therapy groups, breastfeeding support groups, postpartum support groups, educational sessions, changing areas, restrooms, communal showers, and other single-sex programs and spaces, by gender identity and not by biological sex.

Various edits handwritten on the draft suggest referring to trans people’s genitals as “pseudo-genitalia” as well as calling puberty blockers a “gateway drug” (Pl. 282), and these edits would ultimately be incorporated into the agency’s final report (Pl. 297A). Van Mol is on the board of elders at the Bethel Church of Redding, California, and teaches bioethics at the Bethel School of Supernatural Ministry, whose students are well-known in the community for attempting to reanimate dead bodies with “miracles”.

Plaintiffs’ trial exhibit 282. Draft GAPMS determination on gender affirming surgery (with handwritten notes), May 2022. Phrase underlined in red: ‘they state that delaying pubertal onset can provide extra time’. Handwritten margin note in red: ‘5 studies = gateway drug’.

In a 55-page list of references provided to AHCA, Van Mol asserts “transgenderism is an overarching ideology”, attributing this term to Ken Zucker (Pl. 286A). During early May, Van Mol appeared to be attempting to radicalize AHCA’s Jason Weida with anti-Semitic conspiracy theories about “the rich, white men institutionalizing transgender ideology” and “the billionaires behind the LGBT movement” (Pl. 284, 285). Texting Weida about these articles, Van Mol said on May 6, 2022: “Jason, I sent that only to you to minimize scatter risk.” (Pl. 290). Van Mol later emailed Weida and four lawyers to discuss SEGM’s failed anti-trans Resolution 27 (2022) at the American Academy of Pediatrics (Pl. 347).

Plaintiffs’ trial exhibit 284. Email. From: Andre Van Mol, 95andrev@gmail.com. Sent: Friday, May 6, 2022, 12:07 PM. To: Weida, Jason, Jason.Weida@ahca.myflorida.com. Subject: Pharma info. Body: Hi, Jason. Thanks for allowing me to help with this project. I enjoyed our team time this morning. Here are the articles I spoke of today. Financing the movement and its tactics: Jennifer Bilek, The Billionaires Behind the LGBT Movement, firththings.com, Jan. 21, 2020. https://www.firstthings.com/web-exclusives/2020/01/the-billionaires-behind-the-lgbt-movement Jennifer Bilek, ‘Who Are the Rich, White Men Institutionalizing Transgender Ideology?’ the federalist.com, Feb. 20, 2018. https://thefederalist.com/2018/02/20/rich-white-men-institutionalizingtransgender-ideology/ James Kirkup details a handbook attributed to the Dentons law firm, Thomas Reuters Foundation, and the International Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Youth & Student Organisation (IGLYO), outlining the tactics by which trans lobbies influenced public bodies, politicians, officials, education and even police forces so fast and well. ‘The document that reveals the remarkable tactics of trans lobbyists,’ blogs.spectator.co.uk, 2 Dec 2019. https://blogs.spectator.co.uk/2019/12/thedocument-that-reveals-the-remarkable-tactics-of-trans-lobbyists/ The Dentons.Reuters.IGLYO document: https://www.iglyo.com/wp-content/uploads/2019/11/IGLYO_v3-1.pdf Andre

Plaintiffs’ trial exhibit 285. Email. From: Andre Van Mol. Sent: Saturday, May 7, 2022 8:04 PM EDT. To: Weida Jason; Matt.Brackett@ahca.myflorida.com; Devona.Pickle@ahca.myflorida.com. Subject: Articles. Attachments: LGBTQ+_A Front For The Techno-Medical Complex.pdf, Stryker Corporation and the Global Drive for Medical Identities.pdf, The ACLU Gets Fat on Pharma and Tech Funding_Part ll.pdf, Martine Rothblatt A Founding Father of the Transgender Empire.pdf, ATT00005.txt. Body: Hi, Jason, Devona, and Matt. Besides the 3 article links already sent on who the financiers are for the trans movement, I've read through several more today and think these 4 are the best of that lot for establishing the connection to big pharma/biotech/philanthropy profiteering in the clothes of being rights advocates.

Core SEGM members guide AHCA’s report

On May 17, consultants Ema Syrulnik and Evgenia “Zhenya” M. Abbruzzese (zhenyapdx/E. Abbruzzese) of SEGM also met with AHCA staff to provide feedback on the report, with Syrulnik sending a link to an article on a Cochrane blog that would later be cited in the final GAPMS report (Pl. 338). Publications coauthored by Abbruzzese, Syrulnik, and other SEGM members were cited by the AHCA’s hired anti-trans experts during the GAPMS process (James Cantor, Attachment D) and in their expert declarations in Dekker v. Weida (Levine report; Kaliebe report; Hruz report; Biggs report; Kaliebe rebuttal report; Hruz rebuttal report; Van Meter rebuttal report). Confusingly, Matthew Brackett had stated during deposition on February 8, 2023 that he was the sole author responsible for reviewing literature and drafting the report, with no assistance from others (Doc. 120-6). The plaintiffs’ trial brief highlights this apparent discrepancy (Doc. 199):

Indeed, Van Mol appears to have been the true architect of the GAPMS Report that Brackett claims he solely drafted. (ECF 120-6, Brackett Feb. 8 Dep. at 97:1619, 98:3-8). Brackett testified that he was the only one involved in reviewing the literature and writing the GAPMS Report, and that nobody else provided an outline or assisted with the drafting. He acknowledged only “verbal consultations” with the outside consultants. (See ECF 120-6, Brackett Feb. 8 Dep. at 96:11-97:19, 98:3-21; 104:8-20; 111:4-11, 145:14-146:24.) Van Mol wrote a document to be used in the GAPMS review process, which he sent to Weida and Brackett in early May. (Exs. 328, 328A 5/1/22 email from Van Mol with attachment (ECF 183-31 to 183-32).) AHCA used this document as guidance in drafting the main report. (Compare Ex. 328A, attachment to 5/1/22 email (ECF 183-32), with Ex. 18, June 2022 GAPMS Report report (ECF 175-18).) Van Mol also provided Brackett and Weida with additional sources throughout the process. (Exs. 284; 290; 347, emails from Van Mol to Weida (ECF 182-21, 182-29, 184-12).) And after the GAPMS report was drafted, Van Mol provided seven pages of corrections to the draft. (Exs. 286, 286AB, email from Andre Van Mol dated May 13, 2022 with attachment (ECF 182-23 to 182-25).)

Following the GAPMS report’s publication in June 2022, Andre Van Mol was again commissioned in July 2022 to critique public comments on the rule provided by the AAP, WPATH, the Endocrine Society (Pl. 326, 327), and professors of the Yale School of Medicine (Pl. 348, 312). “GAPMS guy” Jeffrey English stated in deposition on January 23, 2023 that the AHCA’s GAPMS process had never before involved the governor and heads of executive agencies, and had never included outside experts commissioned to produce reports, a public notice of a coverage determination, a press release on the conclusion, or a website to promote the determination (Doc. 199).

The latest filings confirm many concerns noted by Gender Analysis regarding the predetermined nature of the GAPMS process, including our findings of several hired experts’ conflicts of interest due to prior commitments with outside organizations (“Catholic Medical Association members wrote a majority of Florida Medicaid’s anti-trans expert reports”), undisclosed coordination between AHCA and the anti-trans group SEGM (Gender Analysis FLBOM complaint 1), and the extensive involvement of anti-gay conversion therapy advocates (Gender Analysis FLBOM complaint 2).

Essential documents

  • Plaintiffs’ trial brief, April 28, 2023 (doc. 199)
    • Deposition of Jeffrey English, January 23, 2023 (p. 153)
    • Deposition of G. Kevin Donovan, March 22, 2023 (p. 194)
    • Deposition of Jason C. Weida, April 24, 2023 (doc. 200-5)
    • Plaintiffs’ memorandum of law in opposition to defendants’ motion for summary judgment, April 28, 2023 (doc. 200)
    • Plaintiffs’ notice of filing trial exhibits, April 27, 2023 (doc. 175). A list of filed exhibits by number, description, and date.
  • Text message thread between Jason C. Weida and Andre Van Mol, April 1, 2022 – January 27, 2023 (Pl. 290).
  • AHCA Microsoft Teams meeting invitations, April 12 – July 20, 2022 (Pl. 338).
  • May 2022 early draft GAPMS report with handwritten notes (Pl. 282)
  • June 2022, Gender Dysphoria/Transgender Health Care Policy Pathway (Pl. 296)
    • Gender Dysphoria/Transgender Health Care Non-Legislative Pathway (Pl. 295)
    • Projected Rulemaking Timeline (Pl. 294)
  • June 2, 2022 final GAPMS determination (Pl. 297A)
  • June 2022 AHCA template for denying requests for a rule workshop on the challenged exclusion (Pl. 293).
  • Florida Medicaid Comment Summary for Rule 59G-1.050, F.A.C. and Responses, following the July 8, 2022 rule hearing (Pl. 326). Review and critique was provided by Andre Van Mol in reply to public comments from AAP, the Endocrine Society, and Yale School of Medicine professors (Pl. 312).
    • Andre Van Mol “on Alstott (so-called Yale) letter” for AHCA, July 19, 2022 (Pl. 348).
  • Gender Analysis unofficial docket, Dekker et al. v. Weida et al. (4:22-cv-00325).

About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
This entry was posted in Florida, Health care, Law, News, Politics, Rhetoric, Transphobia and prejudice and tagged , , , , , , , , , , , , . Bookmark the permalink.

Leave a Reply

Your email address will not be published. Required fields are marked *