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Iowa Supreme Court strikes down state’s ban on Medicaid paying for gender affirmation procedures

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Carol Ann Beal — photo courtesy of the ACLU of Iowa

In a unanimous decision issued on Friday, the Iowa Supreme Court ruled the state’s prohibition on the use of Medicaid funds to pay for sex reassignment procedures deemed medically necessary by doctors violates the Iowa Civil Rights Act. The decision confirms a district court judge’s ruling in June 2018, striking down the Iowa Department of Human Services (DHS) rule against paying for such procedures.

The decision came in a lawsuit brought by two transgender Iowans, Carol Ann Beal and EerieAnna Good, who sued DHS after the agency decided to deny Medicaid coverage for transition-related procedures ordered by their doctors.

“This has been a long journey since we first started fighting for this gender-affirming health care which some transgender people so desperately need,” Beal said in a statement following the court’s decsion. “I’m so glad we finally won. I’m still processing this. But I’m extremely happy for those people who will come after me, that we’ve made a path for them so that they can get the medical care and surgery they need. That’s one reason I fought so hard for this. It’s opened a door.”

The state’s civil rights act was amended in 2007 to prohibit discrimination based on actual or perceived sexual orientation or gender identity, but the DHS based its decision to deny Medicaid funds to pay for Beal and Good’s treatments on an older section of Iowa’s administrative code that banned the use of Medicaid funds for “procedures related to transsexualism, hermaphroditism, gender identity disorders or body dysmorphic disorders.”

“The Regulation clearly discriminates against transgender Medicaid recipients on the basis of gender identity,” District Court Judge Arthur Gamble wrote in his decision last year.

“DHS failed [in its obligation to keep up with medical science] when it denied coverage to Good and Beal for medically necessary gender affirming surgery,” Gamble found. “This decision was made without regard to the law and facts. The agency acted in the face of evidence upon which there is no room for difference of opinion among reasonable minds.”

In its appeal of the district court’s ruling, DHS argued its rule “does not discriminate based on gender identity because transgender Medicaid beneficiaries and nontransgender Medicaid beneficiaries in Iowa alike are not entitled to gender-affirming surgical procedures,” because the rule bans all providing funds for cosmetic, reconstructive or plastic surgery performed “primarily for psychological purpose.”

Writing for the court, Justice Susan Christensen rejected that argument.

The record does not support the DHS’s position that [it’s rule] against is nondiscriminatory because its exclusion of coverage for gender-affirming surgical procedures encompasses the broader category of ‘cosmetic, reconstructive, or plastic surgery’ that is ‘performed primarily for psychological purposes.’

In a statement released on Friday morning, ACLU of Iowa Legal Director Rita Bettis Austen said, “Today’s decision is historic for civil rights in Iowa, because it is the first Iowa Supreme Court case to recognize the right that transgender Iowans have to nondiscrimination under the Iowa Civil Rights Act in Medicaid — or by any other public accommodation.”

This is the second notable legal victory for transgender Iowans this year.

Last month, a Polk County jury ruled in favor of the plaintiff in the first discrimination lawsuit filed in Iowa by a transgender plaintiff since the Iowa Civil Rights Act was amended to include protection for gender identity. In addition to finding the state illegally discriminated against Jesse Vroegh, a transgender man and former Iowa Department of Corrections employee, the jury awarded him $120,000 in damages.


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