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Judge rules Iowa can’t deny Medicaid coverage for transgender surgery

A state judge cited evidence that gender-affirming surgeries are medically necessary and the cost to the state is negligible.

DES MOINES, Iowa (CN) — Iowa’s denial of Medicaid coverage for sex-reassignment surgery for transgender patients violates the state constitution, a state judge said in a ruling released Monday.

Two Iowa plaintiffs – Aiden Vasquez and Mika Covington – sued after the Iowa Department of Human Services denied their application for Medicaid coverage for surgical procedures to affirm the gender they identify with. The coverage was denied by a private insurer that contracts to administer Medicaid in Iowa. The decision was based on DHS policy and on the Iowa Civil Rights Act, both of which explicitly deny coverage for such surgeries.

“The regulation’s discriminatory exclusion for gender-affirming surgery has no basis in medical science and reflects views on gender dysphoria that have been uniformly condemned by leading medical organizations for decades,” the complaint states.

Polk County District Court Judge William Kelly in Des Moines ruled that both the DHS policy and the Iowa Civil Rights Act are unconstitutional on their face and as applied to Vasquez and Covington. Kelly based his decision on the Iowa Constitution’s equivalent of the equal protection provision of the U.S. Constitution. The ruling was issued Friday but not made publicly available until Monday.

A spokesman for the Iowa Attorney General’s Office said Monday the office is reviewing the ruling and that no decision has been made on whether to appeal the Polk County ruling.

The ACLU of Iowa, which represented Vasquez and Covington, called the ruling a groundbreaking victory.

"This is a historic win for civil rights in Iowa. It recognizes what we've long known, that transgender Iowans must not be discriminated against, and that they are protected by the Iowa Constitution's guarantee of equal protection, as well as by the Iowa Civil Rights Act," ACLU of Iowa Legal Director Rita Bettis Austen said in a statement Monday.

Kelly pointed out in his ruling that the record is “bursting with evidence from petitioners explaining transgenderism and the current opinions of the medical community, as well as testimony from physicians declaring that gender-affirming surgery is medically necessary for these two petitioners who are Iowa Medicaid recipients.”

But, he added, “The court has little information as to why the state should not pay for this type of medically necessary surgery.”

In fact, the judge wrote that the percentage of Iowans on Medicaid who identify as transgender and who qualify as candidates for gender-affirming surgery “is incredibly small and the costs are negligible.”

The ACLU’s effort to win Medicaid coverage for gender-affirming surgery has wended its way through Iowa’s administrative, trial, and appellate courts for five years.

The Iowa Supreme Court ruled in 2019 that the state’s denial of coverage of sex-change surgeries for transgender Medicaid violated the Iowa Civil Rights Act. The GOP-controlled Iowa Legislature promptly responded with an amendment to the Civil Rights Act that said: “This section shall not require any state or local government unit or tax-supported district to provide for sex reassignment surgery or any other cosmetic, reconstructive, or plastic surgery procedure related to transsexualism, hermaphroditism, gender identity disorder, or body dysmorphic disorder.”

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