Medicaid rule discriminatory, Iowa Supreme Court rules

Court sides with transgender women seeking gender affirming surgeries

EerieAnna Good
EerieAnna Good

DES MOINES — An administration code that restricted Iowans from using Medicaid funds for gender-affirming surgeries has been struck down by the Iowa Supreme Court Friday.

In their ruling, the justices upheld a decision made in the 5th District Court this June that agreed with the two transgender women who filed the suit — that denying Medicaid reimbursement for surgeries to treat gender dysphoria is in violation of the Iowa Civil Rights Act.

“The (Iowa Civil Rights Act) gender identity classification encompasses transgender individuals — especially those who have gender dysphoria — because discrimination against these individuals is based on the non-conformity between their gender identity and biological sex,” Justice Susan Christensen wrote in the ruling.

The permanent injunction on the administrative rule remains in place, meaning it can’t be used as a basis to deny Medicaid dollars to individuals seeking these medical procedures.

The court’s decision puts a bookend on a two-year legal battle over the Iowa Department of Human Services’ rule that stated gender reassignment surgeries are not considered medically necessary to restore bodily function, and are therefore exempt from coverage.

However, the state Supreme Court’s ruling did not support the Department of Human Services’ position throughout proceedings that the rule was non-discriminatory because a gender-affirming procedure “encompasses the broader category of ‘cosmetic, reconstructive, or plastic surgery’ that is ‘performed primarily for psychological purposes.’”

“This is the first decision by the Iowa Supreme Court that affirms the rights of transgender Iowans to non-discrimination under the Iowa Civil Rights Act,” said American Civil Liberties Union of Iowa Legal Director Rita Bettis Austen during a news conference Friday.

Department of Human Services officials declined to comment on the ruling.


In 2017, EerieAnna Good of the Quad Cities and Carol Ann Beal of northwest Iowa were denied coverage gender-affirming surgeries by their respective managed care organizations, the insurers who administer health coverage for Medicaid members.

Both women were seeking medical procedures to treat gender dysphoria, a psychological condition in which an individual experiences distress because the gender they were assigned at birth does not match his or her gender identity.

The women, who were represented by the ACLU of Iowa, challenged the law. They argued the administrative rule violated the Iowa Civil Rights Act as well as an equal protection clause in the state’s Constitution.

Bettis Austen said years of medical research has show these procedures are medically necessary for individuals dealing with gender dysphoria.

“Coverage for transition related medical care is essential for some Iowans — it’s literally lifesaving — and denying them care puts them at risk of self-harm and even suicide in addition to other increased medical risk,” Bettis Austen said.

Department of Human Services attorneys maintained the law is not discriminatory because both non-transgender and transgender individuals are denied coverage for procedures performed for psychological purposes.

In June, 5th Judicial District Chief Judge Arthur Gamble ruled in favor of those challenging the ban. Attorneys for the Department of Human Services appealed the decision, and the Iowa Supreme Court heard arguments in January.

“We are thrilled that our state’s ban on transition-related surgical care has been struck down,” said One Iowa Executive Director Daniel Hoffman-Zinnel in a statement. “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. This decision will, quite literally, save lives.”

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