Medicaid recipients and plaintiffs Aiden Vasquez (left) and Mika Covington – Photo: ACLU of Iowa.
An Iowa district court has declared a Republican-led effort to bar Medicaid funds from being used to cover the cost of transition-related surgery for transgender recipients unconstitutional.
Polk County District Judge William Kelly found that a longstanding rule prohibiting Medicaid from covering medically necessary surgery to treat gender dysphoria is discriminatory, unconstitutional, and a violation of the Iowa Civil Rights Act, which prohibits discrimination based on a person’s gender identity.
Kelly also found that the subsequent law, passed by Republicans on a party-line vote in 2019, that sought to cement that insurance exclusion into effect after the Iowa Supreme Court ruled it unconstitutional.
Kelly’s decision comes after a five-year-long fight over Iowa’s insurance exclusion prohibiting public dollars from being used to cover transition-related procedures, based on the outdated idea that such surgeries or treatments are unnecessary or “cosmetic” in nature, rather than medically necessary.
The American Civil Liberties Union, the ACLU of Iowa, and the global law firm Nixon Peabody LLP filed a lawsuit challenging the original insurance exclusion as unconstitutional, a finding upheld by the Iowa Supreme Court two years later.
However, just months after the Iowa Supreme Court’s decision, Republican lawmakers, led by Gov. Kim Reynolds, passed a new law that carved out a section of the Iowa civil rights law’s protections for transgender people by permitting local governments or state agencies to refuse to spend public dollars on transition-related care. The ACLU subsequently sued, leading to Kelly’s decision last week.
“This is a historic win for civil rights in Iowa,” Rita Bettis Austen, the legal director of the ACLU of Iowa, said in a statement. “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.”
“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,” Bettis Austen added. “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.”
Every mainstream medical association, including the American Medical Association, currently holds that gender-affirming surgery is medically necessary, effective at treating gender dysphoria, and can be life-saving for some people.
The two lead plaintiffs in the case, Aiden Vasquez, a 53-year-old trans man from southwest Iowa, and Mika Covington, a 30-year-old trans woman from central Iowa, both qualify for Medicaid and have personal care providers who agree that gender confirmation surgery is essential to treating their gender dysphoria. But with the Republican-approved law in place, both plaintiffs, as well as all other transgender Medicaid recipients, could be forced to pay exorbitant out-of-pocket costs or forego surgery altogether.
With Kelly’s ruling, Vasquez and Covington can now move forward with their fight to force Amerigroup, which oversees all publicly-funded health programs in the state, to cover the costs of their surgeries.
“I am so glad to be able to take the next step forward,” Vasquez said in a statement. “I desperately need this surgery. For me, it’s nothing short of life-saving. 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,” Vasquez added. “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.”
“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,” Covington added. “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. 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.”
Kim Reynolds – Photo: Gage Skidmore
A spokesman for Reynolds told the Longview News-Journal that the governor is “disappointed” with the court’s decision and disagrees that Medicaid should be forced to cover transition-related surgeries. The spokesman also said the governor’s office would be reviewing the decision and exploring all legal options available to them — leaving open the possibility of appealing Kelly’s ruling.
But the national ACLU celebrated the ruling, casting Reynolds’ and Republicans’ actions as motivated by animus against transgender people.
“The blatant attack on transgender Iowans that made this case necessary is part of a nationwide effort to use transgender people as political scapegoats,” John Knight, a senior staff attorney with the ACLU’s LGBT & HIV Project, said in a statement. “Aiden and Mika are two heroic transgender Iowans who join a vast group of courageous transgender people and their allies in Iowa and elsewhere who are fighting back. This win is theirs above all else. The district court’s decision recognizes the humanity of our transgender colleagues, friends, and community members as well as their entitlement to basic fairness. We should expect nothing less.”
FCC Chair Brendan Carr is seeking public comment on proposed changes to the parental ratings system that would flag content related to gender identity.
Federal Communications Commission Chair Brendan Carr is seeking public input on whether television programs that address transgender issues or feature trans or nonbinary characters should carry warning labels.
The FCC oversees broadcast and cable TV companies and helps shape the ratings system that guides parents on whether shows are appropriate for children.
In 1996, Congress gave TV companies the option to create their own voluntary ratings system or adopt one imposed by the FCC. The companies chose to create their own system, forming the TV Oversight Management Board, which developed the TV Parental Guidelines still used today for cable, satellite, and streaming services.
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