Judge William Kelly said Iowa’s Department of Human Services had to provide Medicaid coverage for the surgeries when medically ordered to treat gender dysphoria.
Gender dysphoria is defined by the Mayo Clinic as the “feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics.”
Gender dysphoria commonly begins during childhood, although some people don’t experience it until after puberty or later in life.
The ruling follows a lawsuit brought in April by Aiden Vasquez and Mika Covington, two Iowa residents who worked with the ACLU of Iowa to bring their case to the state.
According to Kelly, the state’s defense of the law did not include a challenge that gender dysphoria is a serious condition medical professionals have recommended surgery as a necessary and effective treatment for both Vasquez and Covington.
He said Medicaid is designed to provide those types of treatments to economically-disadvantaged Iowans, so there is no reason surgery should not be covered.
“Once the medical community determined that surgery is medically necessary to treat this health issue, the government lost its rational basis to refuse to pay for the surgery,” Kelly said in a ruling signed on Friday but posted publicly online Monday. “The law appears to draw an arbitrary distinction. So, there is no plausible policy reason advanced by, or rationally related to, excluding transgender people from Medicaid reimbursement for medically necessary procedures.”
For more reporting from The Associated Press, see below.
About 12 states exclude the surgeries in Medicaid coverage, 18 specifically include gender-affirming care and others do not address it.
Kelly said state and federal courts in the past 16 years have found that gender identity discrimination is a form of sex discrimination which is prohibited under civil rights laws. He also found the law violated the equal protection clause of the state constitution.
Rita Bettis Austen, legal director of the ACLU of Iowa, called the decision “a historic win for civil rights” in Iowa.
“It recognizes what we’ve long known, that transgender Iowans must not be discriminated against, and that they are protected by the Iowa Constitution’s guarantee of equal protection, as well as by the Iowa Civil Rights Act,” Bettis Austen said.
The ACLU of Iowa filed a lawsuit in April against the state of Iowa challenging a 2019 law that allows Medicaid to deny payment for sex reassignment surgeries for transgender residents.
Vasquez and Covington initially sued in 2017 and a state court judge found the policy violated the Iowa Civil Rights Act and the Iowa Supreme Court in 2019 upheld that decision. The court concluded that Iowa’s Medicaid program may not categorically discriminate against transgender people seeking gender-affirming, medically necessary care.
Shortly after the court ruling, Republicans in the Iowa Legislature passed an amendment as part of a last-minute addition to a human services budget bill in response to the court’s ruling. That change stated that any government agency in Iowa may decline to use taxpayer money for “sex reassignment surgery” or “any other cosmetic reconstructive or plastic surgery procedure related to transsexualism, hermaphroditism, gender identity disorder, or body dysmorphic disorder.”
Vasquez and Covington, however, had to take their cases through the Department of Human Services system and apply for surgery, have it denied based on the new law and then again pursue a challenge in court. The Iowa DHS has since denied coverage to them. Vasquez is a transgender man who was diagnosed with gender dysphoria in 2016 and Mika Covington is a transgender woman who was diagnosed with gender dysphoria and began receiving hormone therapy in 2015.
Gov. Kim Reynolds signed the bill into law in May 2019, arguing it only narrowly clarifies that Iowa’s Civil Rights Act does not require taxpayer dollars to pay for sex reassignment and other similar surgeries.
Reynolds’ spokesman Alex Murphy said she is disappointed by the ruling “and disagrees with the district court’s ruling on Medicaid coverage for transgender reassignment surgeries. We are reviewing the decision with our legal team and exploring all options moving forward.”
