Transgender Iowan sues to overturn state’s ban on Medicaid coverage for medically necessary procedures

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Aiden Vasquez. Courtesy of the ACLU of Iowa.

A lawsuit challenging Iowa’s ban on allowing Medicaid to pay for gender-affirming procedures deemed necessary by a doctor was filed in Polk County District Court on Thursday by the ACLU of Iowa and the national ACLU LGBTQ & HIV Project. The groups filed the lawsuit on behalf of Aiden Vasquez, a transgender resident of southeast Iowa.

The Iowa Department of Human Services (DHS) rejected Vasquez’s application to have Medicaid cover the cost of the gender-affirming surgery his doctor considers medically necessary.

“I desperately need this surgery,” Vasquez said during an ACLU of Iowa news conference announcing the lawsuit on Thursday afternoon. “Having to jump through so many hoops just to try to get coverage for the surgery has been mentally and emotionally very draining and difficult. It’s hard knowing that the state has gone out of its way to discriminate against me and block my medical care just because I’m transgender, when other Iowans on Medicaid are able to get coverage for the surgeries they need.”

In March 2019, the Iowa Supreme Court ruled unanimously in a lawsuit brought by the ACLU of Iowa on behalf of EerieAnna Good that the DHS policy of refusing to allow Medicaid to pay for gender-affirming procedures violated the Iowa Civil Rights Act, which was amended in 2007 to prohibit discrimination based on actual or perceived sexual orientation or gender identity.

In that case, DHS argued its policy “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 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 [its 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.’

Christensen, who is now the court’s chief justice, agreed with a district court judge that the DHS policy ignores the scientific and medical consensus, as well as the determination of Good’s doctor, that gender-affirming procedures are health care, not merely cosmetic surgeries.

“This decision was made without regard to the law and facts,” the district court judge wrote of DHS’s actions. “The agency acted in the face of evidence upon which there is no room for difference of opinion among reasonable minds.”

The month following the Iowa Supreme Court’s decision in Good’s case, Republican leaders in the Iowa Senate inserted a provision into the DHS budget bill to amend the Iowa Civil Rights Act and prevent Medicaid funds from being used in gender-affirming medical procedures.

The bill passed both Republican-led chambers of the Legislature, and on May 3, 2019, Gov. Kim Reynolds signed it into law.

Three weeks later, the ACLU of Iowa filed a lawsuit seeking to have the newly created ban on funding declared unconstitutional. The lawsuit was filed on behalf of Vasquez and another transgender Iowan, Mika Covington.

In August 2020, the Iowa Court of Appeals dismissed the lawsuit on procedural grounds. Because DHS had not yet rejected the applications by Vasquez and Covington, the court decided the case was not yet ready to proceed.


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DHS has now rejected Vasquez’s application, and Covington’s is currently under consideration. The ACLU is proceeding with the lawsuit on Vasquez’s behalf, and if as expected, DHS rejects Covington’s application, she will join the lawsuit.

“We are frustrated, our clients are frustrated, we know Iowans are frustrated that the state keeps putting into place this discriminatory policy,” Rita Bettis Austen, legal director of the ACLU of Iowa, said during the news conference.

Bettis Austen called DHS’s policy a violation of the Iowa Constitution because it “facially and intentionally discriminates against people simply because they are transgender.”

“It’s important to realize this policy has no basis in medicine or in science,” Bettis Austen said. “Gender dysphoria is a serious medical condition that in some cases puts people at risk for death by suicide, and significant distress.”

“I would like everyone to understand that we are not talking about cosmetic surgery or something superficial,” Vasquez explained. “This has affected my whole life in a negative way and has threatened my mental well-being. I am a man, but in a body that does not reflect who I am. That’s why this surgery will be life-changing.”

“I have seen too many other transgender people suffer because they are unable to get the care they need.”

Although she is not yet officially a party to the lawsuit, Mika Covington also spoke at the news conference.

Mika Covington with her dog, Teddy. — courtesy of the ACLU of Iowa

“It’s been more than a decade since I have come out as transgender, though I have known I am female long before that,” Covington, who is a University of Iowa student and a member of the patient advisory board of the University of Iowa Hospitals and Clinic, said. “I am currently forced to live in a body that does not align with my gender, the gender that I am in my mind and in my heart. It affects every aspect of my life, creating tremendous stress that triggers anxiety attacks, anguish and other health problems. This surgery is literally life-saving for me. “

“Being able to finally get the surgery that my doctors have determined is medically necessary for me will do nothing less than give me my life back. It will help me build a life in which my body is in harmony with my gender, so I can overcome the depression, lack of confidence, isolation and other problems my gender dysphoria causes.”

One Iowa, a nonprofit that advocates for LGBTQ rights, issued a statement on Thursday in support of the lawsuit.

“Everyone in our communities should be able to access the medically necessary care their doctor has prescribed for them, and that includes individuals who are transgender,” Courtney Reye, the group’s executive director, said. “It can be hard to understand what it means to be transgender, especially if you’ve never met a transgender person.”

“Transgender Iowans are our friends, family members, and co-workers, and they deserve to be treated with dignity and respect when accessing necessary care.”

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