A court has struck down Iowa’s ban on gender-affirming care under its Medicaid plan in what advocates hail as “a historic win for civil rights.”
On Nov. 19, Polk County District Court Judge William P. Kelly ruled it unconstitutional for Iowa to refuse to cover confirmation surgery and other gender-affirming treatments through its state Medicaid program. In a 60-page decision, Kelly noted that research shows providing health care for trans patients can be “affordable and cost-effective and has a low budget impact” and leads to “significant reductions in suicide attempts, depression, anxiety, substance abuse.
“Once the medical community determined that surgery is medically necessary to treat this health issue, the government lost its rational basis to refuse to pay for the surgery,” he wrote. “So, there is no plausible policy reason advanced by, or rationally related to, excluding transgender people from Medicaid reimbursement for medically necessary procedures.”
Last week’s verdict follows a years-long struggle for trans Iowans to have their health needs met under the state’s Medicaid allowances. The ACLU of Iowa won a series of court rulings in 2017 and 2019 that paved the way for trans Medicaid recipients to receive coverage, but state lawmakers overrode those victories just months after the final judgment was handed down. In May 2019, Republican legislators passed a budget bill with an amendment blocking Medicaid coverage for trans-affirming surgeries.
Signing the last-minute provision into law in 2019, Republican Gov. Kim Reynolds said the amendment merely affirmed what had been “the state’s position for a long time.” “This takes it back to the way it’s always been,” Reynolds said in comments reported by the Cedar Rapids CBS news affiliate KGAN. “This has been the state’s position for decades.”
With the two-year-old ban now effectively null and void, the ACLU of Iowa says it’s “relieved” that the legal advocacy group’s clients can “finally get the gender-affirming surgical care that all their doctors agree is medically necessary for them.”
“That I have had to jump through hoops just to try to get coverage for a surgery that could save my life has been mentally, emotionally and physically draining.”
“[This court ruling] 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,” says Rita Bettis Austen, legal director of the ACLU of Iowa, in a statement shared with Xtra.
Lead plaintiff Aiden Vasquez, who has been forced to wait years to receive gender-affirming care as the case makes its way through the courts, likewise attests that he is “glad to be able to take the next step forward.”
“I desperately need this surgery,” he writes in an emailed statement. “For me, it’s nothing short of life-saving. The fact that I have had to jump through hoops 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.”
But despite the recent win, Reynolds has signaled that Iowa may continue challenging the rights of its trans citizens to medically appropriate health care. On Tuesday, the governor said that she is “disappointed” in the ruling and is weighing an appeal.
“My legal team is looking at it and there will be more to come later on,” Reynolds told members of the press, as originally reported by the southwest Iowa radio station KJAN. “But it is just too early, we just got the ruling yesterday and are looking at it and trying to determine what our options are.”
Ten other states continue to exclude trans health coverage in their Medicaid programs, according to the non-profit think tank Movement Advancement Project. These states include Arizona, Georgia, Missouri, Ohio, Tennessee and Texas, many of which have faced lawsuits from groups like the ACLU over their exclusionary policies. Sixteen states do not explicitly state whether surgery and other forms of affirming care are covered under Medicaid.
As advocates across the U.S. continue to lobby for states to repeal policies discriminating against trans patients, fellow ACLU of Iowa plaintiff Mika Covington says the ruling in her case represents a “huge step forward.”
“This care will be life-saving for me because I’m constantly bombarded every day with giving up, with suicidal thoughts, and thoughts of self-harm,” Covington says in a statement. “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.”
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