Des Moines, Iowa — Today two ACLU clients won their lawsuit that challenged the Iowa Department of Human Services ban on Medicaid coverage for medically necessary surgical care for transgender Iowans.
The court found that the ban violates the Iowa Civil Rights Act and Iowa's state constitution. It ordered that DHS should act right away to approve the clients’ physicians requests for pre-approval of coverage under Medicaid.
That means transgender Iowans covered by Medicaid can now get the medically necessary care they need and no longer face Medicaid's sweeping, discriminatory, and categorical exclusion of all transition-related care. That care had been denied in the past, even though it was determined to be medically necessary by an individual’s doctor.
Medicaid otherwise provides coverage for virtually every other type of medical care deemed necessary by a doctor.
Rita Bettis, ACLU of Iowa legal director, said, "Today's decision is historic for civil rights in Iowa, because it recognizes for the first time in a court decision what we've long known, that transgender Iowans are protected by the Iowa Constitution's guarantee of equal protection, as well as by the Iowa Civil Rights Act. We are so relieved for our brave clients that they can finally get the gender confirming surgical care that all their doctors agree is medically necessary for them. We are honored to represent them in their long journey for themselves and for all other transgender Iowans to be treated equally and fairly under the law."
"The court has brought Iowa in line with the current understanding of the critical needs for transgender people," said John A. Knight, senior staff attorney with the American Civil Liberties Union. "By recognizing and rejecting the historic discrimination faced by transgender people, the court is opening the door to the life-saving medical care and necessary gender-affirming treatment that transgender people are too often denied."
The availability of transition-related medical care, including surgeries for those who need it, is recommended by the American Medical Association, American Psychological Association, the American Psychiatric Association, the American Academy of Family Physicians, the National Association of Social Workers, and many other professional associations.
"Our clients' doctors have prescribed this surgical care, which they have found to be medically necessary. It is being withheld for non-medical reasons based on a blanket ban on coverage that stems from outdated and faulty assumptions about the nature of transgender health care," Bettis said.
As the result of this sweeping exclusion, all surgical treatments for gender dysphoria are excluded from coverage, even though the same or substantially equivalent treatments are provided to cisgender Iowans.
"For example, Iowans who are not transgender routinely receive coverage for a medically necessary mastectomy—but a transgender Iowan would be banned from coverage for the same care to treat gender dysphoria regardless of medical need. That's a violation of the Iowa Civil Rights Act and equal protection under the Iowa Constitution," Bettis said.
Despite clear medical standards and legal obligations, Iowa's Medicaid program refuses to cover transition-related medical care. Excluding Iowa Medicaid coverage for transgender people who need it is a violation of the Iowa Civil Rights Act—which specifically prohibits discrimination based on gender identity—and the Iowa Constitution—which assures equal protection for all Iowans.
The court decision held, "At the time the Regulation was adopted more than two decades ago, the ICRA did not prohibit discrimination on the basis of gender identity. It does now."
It went on to explain that "Gender Dysphoria has a biological component and the current medical consensus no longer supports the conclusion that gender affirming surgery is not therapeutic. Medical thinking and Iowa law has changed. The Regulation has not kept pace with law and medicine."
The ACLU won the lawsuit on behalf of clients Carol Ann Beal of northwest Iowa and EerieAnna Good of the Quad Cities.
Carol Ann had the following reaction: "This has been a long time coming. I'm so glad I can get the care I need, and I'm glad that other Iowans can now get the same care. Transition-related care is a medical issue, plain and simple. It's like any other surgery that a doctor would recommend for you or a family member. Public or private insurance would pay for it, and you'd just do it and move ahead with your life. I look forward to the day when someone fighting to get the transition-related medical care they need isn't in the news because they had to go to court to fight for it. But I'm doing it because someone needs to be the trailblazer here. I want to make it easier for the younger people who need this surgery, so they don't have to go through the struggles I have had to go through."
In 2014, the U.S. Department of Health and Human Services invalidated its ban on Medicare coverage for surgery and other transition-related care. Since then, more and more states have also eliminated their outdated bans on Medicaid coverage for healthcare for transgender people in those states.
Attorneys Seth Horvath, Tina B. Solis, and F. Thomas Hecht, Litigation Partners at the Chicago office of the national firm Nixon Peabody LLP, are cooperating attorneys volunteering countless hours and expertise on the case. They had the assistance of Anders Van Marter, paralegal/IT specialist at Nixon Peabody.
Photos of Carol Ann, ACLU logos, and a copy of the decision, are available here.