When a doctor recommended Aidan Zingler undergo gender reassignment surgery, the 27-year-old hoped it would mean the end of a lifetime of anguish.
A science-fiction writer living in Des Moines, Zingler was born into a female body, which caused increasing torment as the years passed.
Surgery promised a salvation. But Iowa’s Medicaid program refused to cover it, saying it was cosmetic and not the medical necessity Zingler’s doctor claimed.
“It made me feel like I wasn’t a person,” Zingler, who is now 34 and identifies as nonbinary, recalled in a phone interview. “It was disregarding what a doctor said were my medical needs. I felt like I wasn’t a person and my rights weren’t being regarded.”
The ongoing political and legal debate in Iowa over using the publicly funded Medicaid agency to provide transgender health care services for those qualified to enroll in the program underscores how states across the nation sharply diverge on the issue.
Iowa recently enacted a law denying Medicaid coverage for transition services, and Medicaid policies in eight states exclude sexual reassignment treatment, according to the Movement Advancement Project, a nonprofit group based in Colorado. However, officials from two of the eight states — Ohio and Wyoming — said they no longer are following policies that exclude transgender health services.
Twelve states also specifically exclude transition-related services from health benefits for their state employees.
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On the other hand, Maine announced last month it would begin covering transition services under Medicaid, and judges in Wisconsin, Minnesota and California recently ruled that health care providers in those states can’t discriminate based on gender identity.
Twenty-two states and the District of Columbia have prohibitions against discriminating in health care on the basis of gender identity.
LGBTQ advocates say transgender restrictions stem from prejudice, not medical science.
The American Medical Association and other professional medical organizations have backed public and private health insurance coverage for treating gender dysphoria as recommended by a patient’s physician.
Gender dysphoria is defined as a conflict between a person’s physical gender and the gender with which one identifies. The American Psychiatric Association says it is often accompanied by extreme distress, which can interfere with the ability to function.
But religious conservatives, including the Family Research Council, staunchly oppose such insurance coverage on the public dime.
“We would oppose including gender identity as a protected category in any anti-discrimination codes,” said Peter Sprigg, a senior fellow for policy.
Sprigg said being transgender is a lifestyle choice, not a biological imperative — a view at odds with that of medical professional organizations including the AMA, the American Psychiatric Association and the American Psychological Association.
In May, the Trump administration issued regulations beefing up protections for medical providers who refuse to provide the care for religious reasons.
A month later, the administration proposed to overturn an Obama-era policy prohibiting discrimination by gender identity under the Affordable Care Act.
The ACA and Obama administration guidelines generally have been interpreted by courts to prohibit discrimination in two ways:
Services deemed medically necessary for some patients, such as mastectomies for women with breast cancer, cannot be denied to others, such as transitioning transgender patients with gender dysphoria. The same is true of other transition medical services, such as hormone treatment and facial surgery.
In Iowa, the state Supreme Court unanimously ruled in March that excluding sex reassignment surgeries from Medicaid coverage violates the state’s Civil Rights Act.
But only weeks later, in the waning days of its session, Iowa’s Republican-controlled Legislature amended the budget to say the state doesn’t have to pay for procedures related to sex reassignment.
Neither the Republican sponsor of the amendment, state Sen. Mark Costello, nor the office of Republican Gov. Kim Reynolds, who signed the bill, responded to requests for comment. In introducing the bill, Costello said he didn’t accept that such surgeries were “always medically necessary.”
When Reynolds signed the bill, her office said it “simply clarifies that Iowa’s Civil Rights Act does not require taxpayer dollars to pay for sex reassignment and other similar surgeries. This returns us to what had been the state’s position for years.”
The Iowa ACLU, which won the earlier ruling in the Iowa Supreme Court, now filed suit to overturn the new law. But last Thursday, a judge in Des Moines dismissed the case, saying plaintiffs had not exhausted possible administrative remedies before returning to court.
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The suit, filed on behalf of transgender Iowans Mika Covington of central Iowa and Aiden Vasquez of southeast Iowa couldn’t continue because it was too early for courts to assess consequences of the law.
Courts in several cases have ruled against states that have denied Medicaid coverage of reassignment surgeries. Last year, a federal judge in Wisconsin issued a preliminary injunction requiring the state Medicaid agency to cover surgeries for four transgender patients.
The judge, William Conley of Wisconsin’s western district, said the state’s exclusion of transgender surgeries violated the ACA by treating “transgender individuals differently on the basis of sex.” Conley also certified that the case will now move forward as a class-action lawsuit.
Federal judges in Minnesota and California issued rulings enforcing a prohibition against gender identity discrimination. In Maine, the administration of Democratic Gov. Janet Mills announced last month its Medicaid agency would begin covering transition-related medical services.
Zingler had depression and was twice hospitalized for suicidal thoughts after Iowa denied the sex-reassignment surgery under Medicaid.
“I didn’t think I’d ever make it to age 40,” Zingler said.
Zingler eventually was able to have the surgery after getting a job with private health care health benefits.
But the actions by the Iowa Legislature and governor to prevent the use of Medicaid are a blow to other transgender people, Zingler said.
“That was so devastating that I spent the weekend trying to console trans people and trying to keep them from committing suicide.”
Stateline is a reporting initiative of the Pew Charitable Trusts.