Iowa Justices Say Medicaid Covers Sex-Change Surgery

DES MOINES, Iowa (CN) – The Iowa Supreme Court ruled unanimously Friday that the state’s Medicaid program must cover the cost of sex-change operations for transgender persons.

Two Iowa women medically diagnosed as suffering from gender dysphoria, as defined by the American Psychiatric Association, appealed the Iowa Department of Human Services’ refusal to pay for sex-reassignment surgeries.

Carol Ann Beal. (ACLU of Iowa via AP)

On Friday, the Iowa Supreme Court found that the department violated Iowa’s Civil Rights Act, which includes gender identity among the characteristics protected from illegal discrimination.

Iowans EerieAnna Good and Carol Ann Beal, who originally sued the state in Polk County District Court, were represented by American Civil Liberties Union of Iowa Legal Director Rita Bettis Austen in Des Moines and F. Thomas Hecht with Nixon Peabody in Chicago.

“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 released by the ACLU Friday. “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.”

EerieAnna Good. (ACLU of Iowa via AP)

Good said the decision helps people understand why sex-reassignment surgery is needed. “So many people still don’t understand that this is not something we need for trivial or cosmetic reasons,” she said. “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.”

The Iowa attorney general’s office, which represented the state, said in a statement Friday that the ruling helps clarify the law.

“As the ruling showed, this case presented a difficult question involving individual rights and the state’s interests,” it said. “This issue was a first for Iowa’s courts, and we thank the court for its guidance and for resolving this issue.”

While the plaintiffs raised equal-protection claims, the Iowa Supreme Court dodged constitutional issues and focused entirely on the conflict between the Iowa Civil Rights Act protection for transgender Iowans and the Department of Human Services rule that explicitly bans Medicaid coverage for sex-reassignment surgery.

Iowa’s civil rights statute says it is “unfair or discriminatory” for any agent or employee of a “public accommodation” to deny services based on gender identity.

Iowa’s gender identity classification includes transgender people who have gender dysphoria “because discrimination against these individuals is based on the nonconformity between their gender identity and biological sex,” Justice Susan Christensen wrote for the state’s high court.

Christensen noted history supports the court’s decision.

“Nearly forty years ago, the U.S. Court of Appeals for the Eighth Circuit ruled in Pinneke v. Preisser that it was improper for the Iowa DHS to informally characterize sex reassignment surgery as ‘cosmetic surgery’ in its denial of sex reassignment surgery,” she wrote. “Prior to Pinneke, the DHS had an unwritten policy of excluding sex reassignment surgeries from Medicaid coverage based on Medicaid’s coverage limitations on ‘cosmetic surgery’ and ‘mental diseases.’”

In response to the 1980 Eighth Circuit ruling, Iowa amended its Medicaid rule to clarify that the rule excluded Medicaid coverage for “sex reassignment procedures” and “gender identity disorders.”

“After the DHS amended the rule to bar Medicaid coverage for gender-affirming surgery, the legislature specifically made it clear that individuals cannot be discriminated against on the basis of gender identity under the [Iowa Civil Rights Act],” Christensen wrote.

Good and Beal’s appeal drew six friend-of-the-court briefs in support of the petitioners, including one submitted by the American Medical Association and other medical and mental-health professionals.

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