Eighteen state attorneys general signed a brief asking a federal judge in Florida to allow states to ban gender-affirming care for transgender people from being covered under state Medicaid programs, using inflammatory language to explain why trans people shouldn’t have equal access to health care.

Last year, the Florida Agency for Health Care Administration (AHCA) finalized a rule banning healthcare providers from billing the state’s Medicaid program for trans people’s gender-affirming care, a rule that covered puberty blockers, hormone therapies, and surgical procedures for adults. Medicaid is a joint federal and state program providing healthcare coverage for low-income people.

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Four trans people and their families sued in federal court for access to needed health care and U.S. District Court Judge Robert Hinkle invalidated AHCA’s rule this past June with a scathing 54-page opinion. “Gender identity is real,” Hinkle wrote, accusing AHCA of making the rule “for political reasons.”

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“Pushing individuals away from their transgender identity is not a legitimate state interest,” Hinkle wrote.

Florida is appealing the decision to the U.S. Court of Appeals for the Eleventh Circuit. Eighteen Republican attorneys general from other states signed a briefsupporting Florida, arguing that doctors are greedily pushing gender-affirming care on people to make money, including the doctors who work for national medical organizations like the American Academy of Pediatrics and the Endocrine Society, which all support access to gender-affirming care for transgender people. The brief’s point was that Judge Hinkle relied on the research of the medical organizations and heeded their opinions more than the odd doctors Florida was able to find to say that trans people don’t need gender-affirming care. 

“Medical interest groups, composed of physicians self-interested in Medicaid coverage, are not neutral arbiters of ‘medical opinion,’” the Republicans wrote, accusing the organizations of stifling debate.

The argument is similar to one that AHCA made in the original case that Hinkle rejected, calling it “fanciful to believe that all the many medical associations who have endorsed gender-affirming care… have so readily sold their patients down the river.”

In June, Hinkle ruled that AHCA’s rule violates the federal Medicaid statute, the Equal Protection Clause of the Fourteenth Amendment, and the Affordable Care Act. He also ordered the state to cover gender-affirming care for transgender people on the state’s Medicaid program.

“I am extremely relieved,” said August Dekker, a 29-year-old transgender man and the lead plaintiff in the case. “Florida’s policy effectively denied me the treatment my doctors recommended,” he said. “Now access to that lifesaving, critical care can continue.”

Advocacy groups estimate that 9,000 transgender people in Florida use Medicaid to fund their treatments.

The states that signed the brief are Alabama, Arkansas, Tennessee, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Mississippi, Missouri, Montana, Nebraska, South Carolina, Texas, Utah, Virginia, and West Virginia.