Metro Weekly

Iowa’s Ban on Transgender Medicaid Coverage Remains Struck Down

The Iowa Supreme Court dismissed the state's appeal of a ruling finding its ban on Medicaid coverage for gender-affirming care is unconstitutional.

Iowa plaintiffs and Medicaid recipients Aiden Vasquez (left) and Mika Covington sued over the state’s ban on Medicaid coverage for gender-affirming care. – Photo: ACLU of Iowa.

On Friday, the Iowa Supreme Court dismissed an appeal by the state challenging a judge’s ruling that a state rule banning Medicaid from covering gender-affirming surgery is unconstitutional.

The high court ruled that the state’s appeal was moot, because the Iowa Department of Health and Human Services had previously paid for the transition-related surgeries of the two transgender plaintiffs in the case.

In 2021, Polk County District Court Judge William Kelly ruled in favor of two Iowans –Aiden Vasquez, a transgender man, and Mika Covington, a transgender woman, both Medicaid recipients — who sued after being denied coverage for gender-affirming surgery.

In that ruling, Kelly had found that the state’s ban on Medicaid coverage violated a 2007 law amending the Iowa Civil Rights Act to prohibit discrimination against people based on gender identity.

He also ruled that a subsequent law amending the Iowa Civil Rights Act to prohibit Medicaid dollars from being used to pay for gender-affirming treatments — approved on a party-line vote by Republicans and signed into effect by Republican Gov. Kim Reynolds in 2019 — was also unconstitutional.

The state appealed Kelly’s decision, but shortly afterward, the state Department of Health and Human Services agreed to pay Vasquez and Covington’s surgical expenses. 

“Choices have consequences, and in this case, the appellant’s choices prompt us to dismiss its direct appeal as moot,” Iowa Supreme Court Justice Thomas Waterman wrote on behalf of the court, citing DHS’s actions. 

Waterman noted that while the state had asked for a ruling on whether the 2019 Medicaid coverage ban was unconstitutional, the court was declining to rule on the validity of that decision at this time, writing: “We save the constitutional issues for another day, presumably with a better-developed record.”

Although the court dismissed the appeal based on DHS’s prior actions, Waterman wrote, on the court’s behalf, that the state had failed to provide evidence or statistics to justify their assertion prohibitions on coverage for gender-affirming care were a cost-saving measure.

Waterman also noted that the U.S. Supreme Court is expected to decide on a similar case involving coverage for transition-related treatments, which will set a national precedent on the issue.

The American Civil Liberties Union of Iowa, which represented Vasquez and Covington in their lawsuit, celebrated the court’s dismissal of the state’s appeal, which keeps Kelly’s ruling in place. 

Rita Bettis Austen, the legal director of the ACLU of Iowa, told the Des Moines Register that the state has not enforced the 2019 Medicaid ban since Kelly issued his ruling two years ago, thereby allowing transgender Medicaid recipients to obtain coverage for gender-affirming treatments.

“We know that this care is literally lifesaving for people who need it,” Bettis Austen said in a statement. “Today’s dismissal of the state’s appeal leaves intact the Iowa district court decision that ordered the state to allow our clients to finally get the gender-affirming surgical care that all their doctors agree is medically necessary for them.

“We are honored to represent Aiden and Mika 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,” she added.

Vasquez described the lawsuit as a “long, incredibly difficult fight” that consumed much of the last four years of his life but expressed pride in taking part in it, expressing hope that it would set a precedent for other cases involving denials of gender-affirming care.

“For me and many others, being transgender is not easy and something that many other people may not yet understand. My gender dysphoria means I have a body that doesn’t match who I know I am — a man. This is made worse by a society that labels me as wrong or sinful, mentally ill, or odd, which is not the case,” Vasquez said in a statement. “I am glad the decision from the district court is still the law because this ban has prevented many transgender people form getting necessary care. Our society is slowly realizing that everyone deserves to be treated with respect, dignity and allowed healthcare and equal opportunities.”

Mika Covington said in a statement that she recalled how “devastating” it felt after Iowa lawmakers deliberately sought to gut the Iowa Civil Rights Act by amending it to bar Medicaid from covering gender-affirming treatments.

“I am so glad that the decision from the district court saying the ban on gender-affirming care in Medicaid is unconstitutional is still in place,” Covington said in a statement. “I am glad that Iowa Medicaid can no longer enforce the rule that specifically prohibits transgender people from getting certain types of surgery, including surgery they would cover for people who are not transgender. That’s the way it should be when it comes to medically necessary care. A person needs surgery, recommended by their doctor, and insurance pays for it.”

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