Good v. Iowa Dep't of Human Servs.

Decision Date08 March 2019
Docket NumberNo. 18-1158,18-1158
Citation924 N.W.2d 853
Parties EerieAnna GOOD and Carol Beal, Appellees, v. IOWA DEPARTMENT OF HUMAN SERVICES, Appellant.
CourtIowa Supreme Court

Thomas J. Miller, Attorney General, Matthew K. Gillespie and Anagha Dixit, Assistant Attorneys General, for appellant.

Rita Bettis Austen of ACLU of Iowa Foundation, Des Moines, John Knight of ACLU Foundation LGBT & HIV Project, Chicago, Illinois, and F. Thomas Hecht, Tina B. Solis, and Seth A. Horvath of Nixon Peabody LLP, Chicago, Illinois, for appellees.

Bob Rush of Rush & Nicholson, PLC, Cedar Rapids, and Steve Sanders of Maurer School of Law, Indiana University, Bloomington, Indiana, for amici curiae Iowa Scholars of Law, History, Bioethics, Gender, and Sexuality.

Paige Fiedler of Fiedler Law Firm, P.L.C., Johnston, Robert R. Stauffer and Lindsey A. Lusk of Jenner & Block LLP, Chicago, Illinois, and Devi M. Rao of Jenner & Block LLP, Washington, D.C., for amici curiae The American Medical Association, The Iowa Medical Society, The American College of Physicians, Mental Health America, National Association of Social Workers, and GLMA: Health Professionals Advancing LGBT Equality.

Sharon Malheiro and Katelynn T. McCollough of Davis Brown Law Firm, Des Moines, for amici curiae One Iowa, Individual Transgender Iowans, and Allies.

Joshua Matz and John C. Quinn of Kaplan Hecker & Fink, New York, New York, and Joseph C. Glazebrook, Des Moines, for amici curiae Lambda Legal Defense and Education Fund, Inc., National Center for Transgender Equality, Transgender American Veterans Association, Transcend Legal, Transgender Legal Defense and Education Fund, Transgender Allies Group, Transgender Resource Center of New Mexico, and The Southern Arizona Gender Alliance.

Roxanne Barton Conlin of Roxanne Conlin & Associates, P.C., Des Moines, and Matt M. Fogelberg, and Paul E. Bateman Jr. of Sidley Austin LLP, Chicago, Illinois, for amici curiae National Health Law Program, National Women’s Health Network, and Chicago Lawyers’ Committee for Civil Rights.

Katie Ervin Carlson of Timmer & Judkins, P.L.L.C., West Des Moines, and Lindsay Nako and Daniel J. Nesbit of Impact Fund, Berkeley, California, for amici curiae Impact Fund, et al.

CHRISTENSEN, Justice.

In 2007, the Iowa legislature amended Iowa Code chapter 216—the Iowa Civil Rights Act (ICRA)—to add "gender identity" to the list of protected characteristics. See 2007 Iowa Acts ch. 191, §§ 5, 6 (codified at Iowa Code § 216.7(1)(a ) (2009) ). We must now determine whether the language of Iowa Administrative Code rule 441—78.1(4) pertaining to the prohibition of Iowa Medicaid coverage of surgical procedures related to "gender identity disorders" violates the ICRA or the Iowa Constitution. The appellees are transgender women and Iowa Medicaid recipients who sought Medicaid coverage for gender-affirming surgical procedures to treat their gender dysphoria

. The appellees’ managed care organizations (MCOs) denied coverage for their surgeries pursuant to rule 441—78.1(4). An administrative law judge (ALJ) and the director of the Iowa Department of Human Services (DHS) affirmed the MCOs’ decisions based on rule 441—78.1 ’s exclusion of coverage for gender-affirming procedures.

After exhausting intra-agency appeals, the appellees sought judicial review. The district court consolidated their cases and concluded the challenged portions of rule 441—78.1(4) violate the ICRA and the equal protection clause of the Iowa Constitution. The district court also determined the DHS’s denial of Medicaid coverage for gender-affirming surgeries was reversible because it would result in a disproportionate negative impact on private rights and the decision was unreasonable, arbitrary, and capricious. We retained the DHS’s appeal. On our review, we affirm the judgment of the district court because the rule violates the ICRA’s prohibition against gender-identity discrimination. Because of this, we adhere to the doctrine of constitutional avoidance and do not address the constitutional claim.

I. Background Facts and Proceedings.

EerieAnna Good and Carol Beal are transgender women who have gender dysphoria

. Gender dysphoria is a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), codified as diagnostic code section 302.85, which "refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender." Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental Disorders 451 (5th ed. 2013). The DSM-V provides the following diagnostic criteria for gender dysphoria in adults:

A. A marked incongruence between one’s experienced/ expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:
1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics ....
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender ....
3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Id. at § 302.85, at 452–53.

At their administrative hearings, Good and Beal each entered into the record an affidavit in support of their appeal from Dr. Randi Ettner, Ph.D., a specialist and international expert in the field of gender dysphoria

. Dr. Ettner concluded that the findings of the Iowa Foundation Report, the DHS Rulemaking Notice, and the DHS Rule Adoption Notice used to justify rule 441—78.1(4)"are not reasonably supported by scientific or clinical evidence, or standards of professional practice, and fail to take into account the robust body of research that surgery relieves or eliminates Gender Dysphoria." She explained, "Without treatment, gender dysphoric individuals experience anxiety, depression, suicidality, and other attendant mental health issues." Dr. Ettner described the accepted standards of medical care to alleviate gender dysphoria, which involve the following options: socially transitioning to live consistently with one’s gender identity, counseling, hormone therapy, and gender-affirming surgery to conform one’s sex characteristics to one’s gender identity. The State presented no evidence to the contrary.

According to Dr. Ettner, "[o]f those individuals who seek treatment for [g]ender [d]ysphoria, only a subset requires surgical intervention." Good and Beal are among the subset of individuals seeking treatment for gender dysphoria

whose physicians have concluded that gender-affirming surgery is necessary to treat their gender dysphoria.

Good is a twenty-nine-year-old transgender woman and Medicaid recipient who was officially diagnosed with gender dysphoria

in 2013, though she began presenting herself as a female fulltime in 2010. Good began hormone therapy in 2014 and legally changed her name, birth certificate, driver’s license, and Social Security card to align with her gender identity in 2016. Good’s gender dysphoria intensifies her depression and anxiety. After her healthcare providers determined that surgery was medically necessary to treat her gender dysphoria, Good initiated the process to seek Medicaid coverage of her gender-affirming orchiectomy procedure from her MCO, AmeriHealth Caritas Iowa (AmeriHealth), in January 2017.

Beal is a forty-three-year-old transgender woman and Medicaid recipient who was officially diagnosed with gender dysphoria

in 1989. Beal began presenting herself as a female fulltime at the age of ten and began hormone therapy in 1989. She legally changed her name, birth certificate, driver’s license, and Social Security card to align with her gender identity in 2014. Beal experiences depression and anxiety due to her gender dysphoria. Beal’s healthcare providers have concluded gender-affirming surgery is medically necessary to treat her gender dysphoria

. She began seeking Medicaid coverage for a gender-affirming vaginoplasty, penectomy, bilateral orchiectomy, clitoroplasty, urethroplasty, labiaplasty, and preineoplasty from her MCO, Amerigroup of Iowa Inc. (Amerigroup), in June 2017.

Medicaid is a joint federal-state program established under Title XIX of the Social Security Act that helps states provide medical assistance to eligible low-income individuals. See Exceptional Persons, Inc. v. Iowa Dep’t of Human Servs. , 878 N.W.2d 247, 248-49 (Iowa 2016) ; see generally Iowa Code ch. 249A (2018). The Iowa DHS manages Iowa’s Medicaid program consistent with state and federal requirements through a managed care model that requires Medicaid recipients’ enrollment in an MCO. See Exceptional Persons, Inc. , 878 N.W.2d at 248 ; Iowa Admin. Code r. 441—73.3. The MCO is required to "provide, at a minimum, all benefits and services deemed medically necessary that are covered under the contract with the agency" in accordance with the DHS’s standards. Iowa Admin. Code r. 441—73.6(1) (emphasis added).

Iowa Medicaid generally provides coverage for medically necessary services and supplies provided by physicians subject to a few exclusions and limitations.

For the purposes of this program, cosmetic, reconstructive, or plastic surgery

is surgery which can be expected primarily to improve physical appearance or which is performed primarily for psychological purposes or which restores form but which does not materially correct or materially improve the bodily functions. When a surgical procedure...

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