Iowa Medicaid Program Must Cover Gender-Affirming Care, Judge Rules

Iowa must provide Medicaid coverage for gender-affirmation surgeries, a judge in the state has ruled.

The denial of such coverage violates both the Iowa Civil Rights Act and the equal protection guarantee of the state's constitution, Polk County District Court Judge William P. Kelly ruled Friday, in a decision made public Monday.

The ruling came in a case brought by two transgender Iowans, Mika Covington and Aiden Vasquez, represented by the American Civil Liberties Union, its Iowa affiliate, and attorneys from the firm of Nixon Peabody LLP.

Medicaid is a joint federal-state insurance program that covers medical care for low-income Americans, people with disabilities, and certain others. States have some leeway in setting eligibility requirements. At least nine states specifically exclude gender-affirming procedures.

The Iowa Supreme Court ruled in 2019, in response to an earlier ACLU lawsuit, that a state Medicaid rule preventing the coverage was unlawful. But the Iowa legislature then passed a law that allowed for denial of the coverage, so the ACLU went back to court, resulting in Judge Kelly's ruling.

"The language of Iowa Administrative Code rule 441-78.1(4) pertaining to the exclusion of coverage for sex reassignment surgery in connection to the treatment of transsexualism should be and is hereby held to violate the Iowa Civil Rights Act and the Equal Protection Clause of the Iowa Constitution," Kelly wrote. "The language of the Regulation excluding coverage for sex reassignment surgery for transsexualism shall be stricken from the Regulation and the remaining language must be interpreted and applied in a manner allowing transgender individuals coverage under Iowa Medicaid for medically necessary gender affirming surgery for the treatment of Gender Dysphoria and other relevant diagnoses."

"I am so glad to be able to take the next step forward," Vasquez, a trans man living in southwestern Iowa, said in an ACLU press release. "I desperately need this surgery. For me, it's nothing short of lifesaving. The fact that I have had to jump through hoops and just to try to get coverage for a surgery that could save my life has been mentally, emotionally, and physically draining. It is very hard for me to know that the state has gone out of its way to discriminate against me just because I'm transgender.

"I would like everyone to understand that this is not cosmetic surgery. It is not a whim. This has affected my whole life in a negative way and has affected my well-being. Not all transgender people need surgery, but I do. I am a man, but I was born into a body that I experience as not being who I am without this surgery. That's why this surgery will be life-changing. I have seen too many other transgender people suffer because they can't get the care they need. I'm doing this for them too."

"This is an emotional day for me," Covington, a trans woman in central Iowa, said in the release. "I have been suffering in this body and with gender dysphoria for so long. As with so many other transgender people, because of the lack of medical care, this has been so heavy on me mentally and physically. This care will be lifesaving for me because I'm constantly bombarded every day with giving up, with suicidal thoughts, and thoughts of self-harm. The way transgender people are treated in our society and the way they are denied care is deeply painful. I am so glad we have gotten this recognition of the fundamental right of transgender people for medically necessary care. It's a huge step forward."

"We are so relieved for our brave clients that the court has ordered the state to allow them to finally get the gender-affirming surgical care that all their doctors agree is medically necessary for them," added Rita Bettis Austen, ACLU of Iowa legal director. "We are honored to represent them and the transgender clients who have come before them in this fight, in their long journey for themselves and for all other transgender Iowans to be treated equally and fairly under the law."

It's unclear if the state will appeal. Gov. Kim Reynolds, a Republican, "is disappointed in [the] decision and disagrees with the district court's ruling on Medicaid coverage for transgender reassignment surgeries," a spokesman for Reynolds told the Iowa Capital Dispatch. The governor's staff is "reviewing the decision with our legal team and exploring all options moving forward," the spokesman said.