On Friday, the Iowa Supreme Court issued a historic ruling finding that Iowa’s Medicaid program may not discriminate against transgender people by refusing to cover the costs of any medically necessary gender confirmation surgery.

The American Civil Liberties Union of Iowa, on behalf of EerieAnna Good, a 29-year-old transgender woman from the Quad Cities, and Carol Beal, a 43-year-old transgender woman from northwest Iowa,  sued the state in September 2017 over the state’s prohibition on using Medicaid funds to cover gender confirmation surgery.

Both women were previously denied coverage even though their doctors had deemed their surgeries “medically necessary” to treat their gender dysphoria. Because both qualify for Medicaid — meaning they do not make enough money to pay for the surgery out-of-pocket — both women were forced to forego the treatment. 

The ACLU of Iowa argued that the ban was discriminatory and unconstitutional under the Iowa Civil Rights Act, which prohibits anti-LGBTQ discrimination, as Medicaid typically pays for procedures deemed medically necessary — such as a mastectomy for breast cancer — that are identical to those involved in gender confirmation surgery.

In a unanimous decision, the Iowa Supreme Court rejected arguments made by the Iowa Department of Human Services, which administers the state’s Medicaid program, that the surgeries sought by Good and Beal were primarily for psychological or “cosmetic” reasons, and upheld a lower court ruling that found the ban on transition-related surgery unconstitutional. The court also recognized that the Iowa Civil Rights Act, as amended in 2007, specifically prohibits discrimination based on gender identity.

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“The record does not support the DHS’s position that [the ban] is nondiscriminatory because its exclusion of coverage for gender-affirming surgical procedures encompasses the broader category of ‘cosmetic, reconstructive, or plastic surgery’ that is ‘performed primarily for psychological purposes,'” Justice Susan Christensen wrote for the court. “The DHS expressly denied Good and Beal coverage for their surgical procedures because they were ‘related to transsexualism . . . [or] gender identity disorders’ and ‘for the purpose of sex reassignment.’ Moreover, the rule authorizes payment for some cosmetic, reconstructive, and plastic surgeries that serve psychological purposes— e.g., ‘[r]evision of disfiguring and extensive scars resulting from neoplastic surgery’ and ‘[c]orrection of a congenital anomaly.’

“Further, the history behind the rule supports our holding that the rule’s express bar on Medicaid coverage for gender-affirming surgical procedures discriminates against transgender Medicaid recipients in Iowa under the ICRA,” Christensen continued.

“Nearly forty years ago, the United States Court of Appeals for the Eighth Circuit ruled in Pinneke v. Preisser that it was improper for the Iowa DHS to informally characterize sex reassignment surgery as ‘cosmetic surgery’ in its denial of sex reassignment surgery,” she wrote. “Prior to Pinneke, the DHS had an unwritten policy of excluding sex reassignment surgeries from Medicaid coverage based on Medicaid’s coverage limitations on ‘cosmetic surgery’ and ‘mental diseases.’ After the Eighth Circuit rejected this informal policy, the DHS amended the rule to clarify that the rule excluded Medicaid coverage for ‘sex reassignment procedures’ and ‘gender identity disorders.'”

Professional organizations such as the American Medical Association, American Psychological Association, the American Psychiatric Association, the American Academy of Family Physicians, and the National Association of Social Workers have all supported the idea of lifting insurance exclusions that prevent Medicaid from covering transition-related care.

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In 2014, the U.S. Department of Health and Human Services under the Obama administration lifted its ban on Medicare coverage for surgery and other transition-related care. Since then, several states have begun eliminating bans on Medicaid coverage for transgender people. More recently, courts in Iowa and Wisconsin have begun ruling in favor of transgender state employees whose employer-provided insurance contains exclusions preventing them from receiving coverage for transition-related care.

The plaintiffs and their lawyers celebrated the decision.

“Today’s decision is historic for civil rights in Iowa, because it is the first Iowa Supreme Court case to recognize the right that transgender Iowans have to nondiscrimination under the Iowa Civil Rights Act in Medicaid — or by any other public accommodation,” Rita Bettis Austin, legal director of the ACLU of Iowa, said in a statement. “We are so relieved for Carol and EerieAnna, our brave clients, that they can finally get the gender-affirming surgical care that all their doctors agree is medically necessary for them. We are honored to represent them in their long journey for themselves and for all other transgender Iowans to be treated equally and fairly under the law.”

“This has been a long journey since we first started fighting for this gender-affirming health care which some transgender people so desperately need,” Beal said. “I’m so glad we finally won. I’m still processing this. But I’m extremely happy for those people who will come after me, that we’ve made a path for them so that they can get the medical care and surgery they need.”

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“I’m super happy about this decision,” added Good. “It’s been a long time coming. … It’s hard to believe that it’s taken so many years for Iowa laws to catch up with the reality of transgender Iowans. I’ve been living this reality for many years.

“So many people still don’t understand that this is not something we need for trivial or cosmetic reasons. It’s medical care a doctor is recommending for someone who has a medical need for it,” Good added. “And it can save lives. Transgender people are at such risk for suicide, and I’ve lost transgender friends to suicide. I hope this decision helps change that.”

The LGBTQ rights group One Iowa also praised the decision and noted the importance of the precedent it sets with regard to protecting the civil rights of transgender Iowans.

“We are thrilled that our state’s ban on transition-related surgical care has been struck down,” Daniel Hoffman-Zinnel, the executive director of One Iowa, said 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.”