Des Moines, Iowa — In a historic win for transgender rights in Iowa, the Iowa Supreme Court today ruled that Iowa’s Medicaid program may not categorically discriminate against transgender people seeking gender-affirming, medically necessary care.
The ACLU of Iowa, on behalf of EerieAnna Good of southwest Iowa and Carol Ann Beal of northwest Iowa, brought the lawsuit because the Iowa Department of Human services had in place a sweeping, categorical ban on Medicaid coverage for gender-affirming medical care for transgender Iowans, even when deemed necessary by their doctors. The two women were denied coverage for that medical care.
As the Court recognized, Medicaid otherwise “generally provides coverage for medically necessary services and supplies provided by physicians subject to a few exclusions and limitations.”.
The Iowa Supreme Court decision was unanimous. The Court rejected the arguments made by the Iowa Department of Human Services, which administers Medicaid, that such medical care was primarily for psychological or cosmetic reasons. The unrebutted evidence in this case demonstrated that the care Carol and EerieAnna seek is not cosmetic but is medically necessary for them.
The Iowa Supreme Court recognized that the Iowa Civil Rights Act specifically prohibits discrimination based on gender identity and has done so since 2007. It also affirmed the lower court's decision on this case, which found, “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."
One of the clients, Carol Ann Beal, said, “This has been a long journey since we first started fighting for this gender-affirming health care which some transgender people so desperately need. 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 other client, EerieAnna Good, said “I’m super happy about this decision. It’s been a long time coming. I’m honored and thankful that I’ve been able to see this victory and that the ACLU had my back. It’s hard to believe that it’s taken so many years for Iowa laws to catch up with the reality of transgender Iowans. I’ve been living this reality for many years.
“I’m honored to have the opportunity to do what I have to help the hundreds and thousands of other transgender people out there who definitely need this type of medical care,” EerieAnna said. “So many people still don’t understand that this is not something we need for trivial or cosmetic reasons. It’s medical care a doctor is recommending for someone who has a medical need for it. And it can save lives. Transgender people are at such risk for suicide, and I’ve lost transgender friends to suicide. I hope this decision helps change that.”
Rita Bettis Austen, ACLU of Iowa legal director, 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. We are so relieved for Carol and EerieAnna, our brave clients, that they can finally get the gender-affirming 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.”
John Knight of the ACLU’s LGBT & HIV Project, said, “The ruling means that many transgender Iowans will be able to obtain life-saving medical care that they were unable to get in the past. Denying health care coverage to someone because they are transgender is wrong and extremely harmful to those who need this care. We are thrilled that the Iowa Supreme Court rejected DHS’s effort to minimize the importance of this surgery by labeling it as cosmetic and unanimously struck down this harmful ban on necessary health care.”
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.
Until today, as a result of Iowa Medicaid's sweeping discriminatory exclusion, all surgical treatments for gender dysphoria were 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.
Despite clear medical standards and legal obligations, Iowa’s Medicaid program refused to cover transition-related medical care for Carol Ann and EerieAnna. 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.
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.
The Iowa Supreme Court decision can be read here.
Images of EerieAnna and Carol, as well as the ACLU of Iowa logo, can be found here. The photos were taken by the ACLU of Iowa and we grant permission to reprint and reuse to media outlets.