Iowa justices refrain from ruling on constitutional issue in gender-reassignment case

Declaring that “choices have consequences,” the Iowa Supreme Court on Friday rejected an effort by the state to have the justices decide the constitutionality of a rule that bars Medicaid from paying for sex reassignment surgery.

Noting that the rule isn’t being enforced and that the Iowa Department of Health and Human Services has agreed to pay for such surgeries, the court said the state’s appeal was moot.

The justices said they was declining to rule on the constitutionality of the state’s actions since the issues appeared to be of merely “academic interest to these litigants.” Writing for the court, Justice Thomas Waterman said the justices would “save the constitutional issues for another day,” adding that “the issues concerning Medicaid coverage for adult sex reassignment surgery are of public importance and likely to recur, but not in a manner that will evade appellate review.”

The decision stems from the state’s appeal of a 2021 district court ruling that found legislation amending the Iowa Civil Rights Act violated the Iowa Constitution. That legislation had attempted to strip away protections for transgender Iowans who rely on Medicaid for transition surgery and related procedures.

The district court had also ruled that an Iowa Medicaid rule or regulation blocking Medicaid coverage for medically necessary transgender care violated both the Iowa Constitution and the Iowa Civil Rights Act.

The state appealed that element of the ruling that deals with the Legislature’s amendment to the Iowa Civil Rights Act, arguing that the state’s elected lawmakers have the right to redefine the language of the act or even repeal it in its entirety.

Despite that appeal, the state has abided by the 2021 ruling and stopped denying preauthorization for transgender-related medical procedures. The two plaintiffs in the case, Mika Covington and Aiden Vasquez, have had their procedures approved for payment – which prompted the justices, during January’s oral arguments, to question why the case was before them.

Lawyers for the state argued they were defending the constitutionality of the statute that was passed by the Legislature – but they acknowledged they were going to abide by the district court ruling that declared the law unconstitutional.

At the time, Chief Justice Susan Christensen suggested the state’s approach put the court in a difficult position.

“Doesn’t that kind of put us in a pickle?” Christensen asked. “You’re saying, ‘Hey, by the way, we’re going to pay for it, but we want you to tell us (that) we don’t have to pay for it.’ Aren’t you asking us to do the heavy lifting? … How much weight should we give the fact that you guys said, ‘Uncle’? You said, ‘We’re going to pay for it.’”

The state had argued that while some people characterized the Iowa Legislature’s amendment to the Iowa Civil Rights Act as a “prohibition on government funding” for gender-reassignment procedure, the amendment merely stated that the act does not require to the state to pay for such procedures.

Debate over coverage dates back to 2016.

The issue of coverage for gender reassignment dates back to 2016, when the ACLU of Iowa filed a complaint on behalf of an Iowa Department of Corrections worker, Jesse Vroegh, who had been denied health care coverage for treatment and procedures his doctors said were medically necessary.

A year later, the ACLU of Iowa filed a lawsuit on behalf of transgender clients Carol Ann Beal and Eerie Anna Good in an effort to block an Iowa Medicaid ban on the coverage of medically necessary gender-affirming surgery.

In 2018, a Polk County District Court judge ruled in favor of Beal and Good and blocked enforcement of the Medicaid ban under the Iowa Constitution’s equal protection guarantee and the Iowa Civil Rights Act.

The state appealed that ruling. In the meantime, a Polk County District Court jury ruled in favor of Vroegh in his case, awarding him $120,000 in damages and finding that the state had engaged in sex and gender identity discrimination as prohibited by the Iowa Civil Rights Act.

Three months later, the Iowa Legislature passed a bill amending the Iowa Civil Rights Act to state that government agencies were not required to use public money, including Medicaid, to pay for transition-related surgeries. After the law’s passage, Iowa Medicaid again started denying payment for such procedures.

In 2021, after the state denied Medicaid coverage to Covington and Vasquez, the ACLU sued the state again, which led to the November 2021 district court decision ordering the state to stop denying Medicaid coverage of medically necessary, gender-affirming surgery for transgender Iowans.

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