ACLU challenges Medicaid coverage exclusions for transgender Iowans

The American Civil Liberties Union of Iowa has filed a second lawsuit charging that state government violates the civil rights of transgender Iowans. Plaintiff EerieAnna Good is a Medicaid recipient who has been denied coverage for transition-related surgical care, because Iowa Department of Human Services administrative rules exclude Medicaid coverage for surgery related to “Sex reassignment.”

Professional associations representing doctors, psychologists, psychiatrists, and social workers support transition-related care as medically necessary, and more than a dozen states prohibit transgender exclusions in private health insurance or Medicaid.

In a news release enclosed in full below, ACLU of Iowa legal director Rita Bettis noted that “Iowans who are not transgender routinely receive coverage for a medically necessary mastectomy—but a transgender Iowan would be banned from coverage for the same care to treat gender dysphoria regardless of medical need. That’s a violation of the Iowa Civil Rights Act and equal protection under the Iowa Constitution.” (Since 2007, the Iowa Civil Rights Act has prohibited discrimination on the basis of gender identity.)

A second transgender Iowan, Carol Ann Beal, will likely join this lawsuit after the Iowa DHS finishes processing her appeal of Medicaid’s denial of coverage, the ACLU said.

Last month, the ACLU filed suit on behalf of a former Iowa prison nurse, who “was continuously denied the use of restrooms and locker rooms consistent with his gender identity, because he is transgender,” and also denied “the same level of health care benefit coverage” the state plan provided to employees who are not transgender.

ACLU of Iowa press release, September 21:

ACLU of Iowa Files Lawsuit to Secure Equality in Medicaid Coverage for Transgender Iowans

Des Moines, Iowa —The ACLU of Iowa filed a lawsuit today to challenge the Iowa Department of Human Services’ ban on Medicaid coverage for necessary surgical care for transgender Iowans.

Rita Bettis, ACLU of Iowa legal director, said, “Coverage for transition-related medical care, including surgery, is essential for some transgender Iowans. Every major medical association agrees that denying surgical care to transgender people who have a medical need for that surgical care is dangerous and contrary to prevailing standards of care developed based on decades of research. Our clients’ doctors have prescribed this surgical care, which they have found to be medically necessary. It is being withheld for non-medical reasons based on a blanket ban on coverage that stems from outdated and faulty assumptions about the nature of transgender health care.”

The availability of transition-related medical care, including surgeries, for those who need it is recommended by the American Medical Association, American Psychological Association, the American Psychiatric Association, the American Academy of Family Physicians, the National Association of Social Workers, and many other professional associations.

Iowa Medicaid Categorically Excludes Transition-Related Surgical Care
Iowa’s Medicaid program provides coverage for medically necessary care for virtually every type of medical care. But Iowa law mandates a sweeping and categorical exclusion of all transition-related surgical care, regardless of whether the treatment is medically necessary for the individual recipient.

“As the result of this sweeping exclusion, all surgical treatments for gender dysphoria are excluded from coverage, even though the same or substantially equivalent treatments are provided to non-transgender Iowans,” Bettis said. “For example, Iowans who are not transgender routinely receive coverage for a medically necessary mastectomy—but a transgender Iowan would be banned from coverage for the same care to treat gender dysphoria regardless of medical need. That’s a violation of the Iowa Civil Rights Act and equal protection under the Iowa Constitution.”

Despite clear medical standards and legal obligations, Iowa’s Medicaid program refuses to cover transition-related medical care. Excluding Iowa Medicaid coverage for the medical care transgender people need is a violation of the Iowa Civil Rights Act—which specifically prohibits discrimination based on gender identity—and the Iowa Constitution—which assures equal protection for all Iowans.

Care Essential for Many Transgender People
Daniel Hoffman-Zinnel, One Iowa Executive Director, said, “Through our work with transgender Iowans, we have seen firsthand how powerful, life-changing, and absolutely essential gender-affirming surgery can be for transgender people grappling with gender dysphoria. We cannot sit idly by while this critical treatment is illegally denied to many in our state’s transgender community. One Iowa is proud to stand with the ACLU of Iowa, EerieAnna Good, and Carol Ann Beal to dismantle this discriminatory and misguided Medicaid ban.”

The ACLU of Iowa is filing the lawsuit on behalf of client EerieAnna Good, who lives in the Quad Cities. “This surgery is not just something that I want. It’s something that I very much need to resolve the depression and anxiety I face because my outside fails to match who I know I am: a woman. I’m only 27 and I have my whole life stretching in front of me. I want to have a career. I want to be married and raise kids. I’ve faced a lot of challenges in my life that have made it difficult for me to do these things, but my inability to get the medical care I need has been one of the major roadblocks. This is so important for my health, well-being, and my life.”

Another client, Carol Ann Beal of northwest Iowa, said “Transition-related care is a medical issue, plain and simple. It’s like any other surgery that a doctor would recommend for you or a family member. Public or private insurance would pay for it and you’d just do it and move ahead with your life. I look forward to the day when someone fighting to get the transition-related medical care they need isn’t in the news because they had to go to court to fight for this. But I’m doing it because someone needs to be the trailblazer here. I want to make it easier for the younger people who need this surgery so they don’t have to go through all the struggles I have had to go through.

Carol Ann’s case is currently still before the agency, where she is appealing the denial of coverage to the Department of Human Services with the assistance of the ACLU. Once her appeal is exhausted at the agency level, the ACLU will appeal her case to the district court along with EerieAnna’s.

Other States Have Updated Transgender Care Policies
In 2014, the U.S. Department of Health and Human Services invalidated its old ban on Medicare (stet) coverage for surgery and other transition-related care. Since then, more and more states have also gotten rid of their outdated bans on Medicaid coverage for the health care transgender people in those states need.

John Knight, senior staff attorney with the ACLU’s national LGBT Project, said, “Many states have recognized that these bans are not only discriminatory and extremely harmful, but are completely unjustified in light of the ample medical research supporting the need for the treatment and the inconsequential cost of adding it. There is simply no justification for continuing blatant form of discrimination in Iowa or anywhere else.”

Attorneys Seth Horvath, Tina B. Solis, and F. Thomas Hecht, Litigation Partners at the Chicago office of the national firm Nixon Peabody LLP, are cooperating attorneys volunteering countless hours and expertise on the case. They had the assistance of Anders Van Marter, paralegal/IT specialist at Nixon Peabody.

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