Smith v. Palmer
| Decision Date | 13 October 1998 |
| Docket Number | No. C97-3055-MWB.,C97-3055-MWB. |
| Citation | 24 F.Supp.2d 955 |
| Parties | John SMITH, Plaintiff, v. Charles M. PALMER, in his official capacity as the Director of the Iowa Department of Human Services, Defendant. |
| Court | U.S. District Court — Northern District of Iowa |
Thomas A. Krause of Max Schott and Associates, Des Moines, IA, for Plaintiff.
Daniel W. Hart, Asst. Atty. Gen., Des Moines, IA, for Defendant.
TABLE OF CONTENTS
I. INTRODUCTION AND BACKGROUND .................................................. 957
II. FINDING OF FACTS ............................................................. 958
A. Uncontested Facts ......................................................... 958
B. Contested Facts ........................................................... 959
III. LEGAL ANALYSIS ............................................................... 959
A. Standards For Summary Judgment ............................................ 959
B. Background On The Federal Medicaid Statute ................................ 960
C. Test For Determining The Creation Of A Federal Right ...................... 961
D. The Creation Of Federal Rights Via Implementing Regulations ............... 962
E. Analysis Of Specific Provisions Of The Medicaid Statute And Regulation .... 963
1. 42 U.S.C. § 1396a(a)(17) ............................................... 963
2. 42 C.F.R. § 440.230 ............................................... 964
F. Analysis Of The Merits Of Plaintiff Smith's § 1983 Claims .................. 966
G. Analysis Of The Merits Of Plaintiff Smith's Due Process Claim ............. 967
IV. CONCLUSION ................................................................... 968
This case reminds the court of something the New York Yankees' Hall of Fame catcher Lawrence Peter "Yogi" Berra once said, "It's deja vu all over again". Eighteen years ago, in a case from this district, the Eighth Circuit Court of Appeals held that the State of Iowa's policy of denying Medicaid benefits for sex reassignment surgery constituted an arbitrary denial of benefits based solely on diagnosis, type of illness or condition, and was inconsistent with the objectives of the Medicaid statute. Pinneke v. Preisser, 623 F.2d 546, 549 (8th Cir.1980). Following the decision in Pinneke, the State of Iowa, after conducting a literature review, amended its administrative rules governing Medicaid payments to specifically exclude sex reassignment surgery. This suit is brought by a Medicaid claimant who seeks sex reassignment surgery as a Medicaid benefit. Thus, a court in this district is again confronted with the question of whether the State of Iowa's policy of denying Medicaid benefits for sex reassignment surgery is permitted under Medicaid.
On May 17, 1997, plaintiff John Smith filed his complaint pursuant to 42 U.S.C. §§ 1983, alleging violations of the federal Medicaid statute, 42 U.S.C. § 1396 et seq., and of his constitutional rights. Smith's claims arise from the Iowa Department of Human Services' denial of sex reassignment surgery for Smith.1 Specifically, in Count I, Smith alleges that the denial of sex reassignment surgery violates the federal Medicaid statute and its attendant regulations. In Count II, Smith alleges that the denial of sex reassignment surgery is violative of Smith's right to due process under the Fourteenth Amendment to the United States Constitution.
On June 1, 1998, defendant Charles M. Palmer filed a motion for summary judgment pursuant to Federal Rule of Civil Procedure 56. In his motion for summary judgment, Palmer contends that Smith's allegation of violations of the federal Medicaid statute and its regulations fails to state a cause of action under 18 U.S.C. § 1983. Alternatively, Palmer asserts that, on the undisputed facts presently before the court, such a claim is without merit. On Smith's due process violation claim, while Palmer concedes that Smith has stated a cause of action pursuant to § 1983, Palmer argues that on the undisputed facts such a claim is without merit. On September 15, 1998, after obtaining additional time to respond, Smith filed his resistance to defendant Palmer's motion for summary judgment.2 Before turning to consider the merits of defendant Palmer's motion for summary judgment, the court will first set out the uncontested, as well as contested facts, underlying this litigation.
The record reveals that the following facts are undisputed. The State of Iowa participates in the joint federal-state Medicaid program under Title XIX of the Social Security Act pursuant to a state plan that has been approved by the Secretary of the United States Department of Health and Human Services. Defendant Charles M. Palmer, the Director of the Iowa Department of Human Services, administers the Iowa Medicaid program. Plaintiff John Smith receives Iowa Medicaid benefits as a disabled individual under the "medical needy" coverage group.
Plaintiff Smith has requested payment for sex reassignment surgery from the Iowa Medicaid program. Sex reassignment surgery involves the surgical removal of sexual and reproductive organs of the individual and a series of cosmetic, reconstructive, or plastic surgery procedures to give the individual the appearance of a person of the opposite gender. Plaintiff Smith seeks female to male reassignment surgery.
Sex reassignment surgery involves inpatient hospital services, physicians' services, and prescriptions. Female to male sex reassignment surgery may also involve the use of prosthetic testicles and a penile implant. The number of candidates for sex reassignment surgery in the general population is one out of 50,000, or .002 percent.
The general categories of medical services covered by the Iowa Medicaid program and provided to individuals in the medically needy coverage group include inpatient hospital services, physician's services, prescribed drugs, and prosthetic devices. Smith's requests for payment of sex reassignment surgery, however, have been denied pursuant to Iowa's state plan for medical assistance and Iowa state administrative rules governing the Iowa Medicaid program. Iowa's state plan for medical assistance provides that cosmetic, reconstructive, or plastic surgery is not covered, but exceptions are made for the correction of congenital anomalies, restoration of body form following accidental injury, or revision of disfiguring and extensive scars from neoplastic surgery. Iowa's state plan was last approved by the United States Department of Health and Human Services on January 24, 1994.
The Iowa administrative rules governing the Iowa Medicaid program excludes sex reassignment surgery as part of a general rule excluding cosmetic, reconstructive, or plastic surgery performed primarily for a psychological purpose that does not correct or materially improve bodily functions. In general, cosmetic, reconstructive, or plastic surgery is not an appropriate treatment for psychiatric disorders. The exclusion of sex reassignment surgery was added to the Iowa Administrative Rules by an amendment in 1994. On November 9, 1994, the Iowa Department of Human Services published a notice of intended action regarding the proposed amendment and solicited public comment on it. This notice contained the Iowa Department of Human Services' reasons for proposing to exclude sex reassignment surgery from the coverage under the Iowa Medicaid program. The notice indicated that the Iowa Department of Human Services had a literature review conducted for it by the Iowa Foundation for Medical Care. XVII Iowa Admin. Bull. 730 (Nov. 9, 1994). The notice indicates that the review found that:
*Continuing controversy regarding the definition, diagnosis, cause, and treatment of gender dysphoria, particularly regarding sex reassignment surgery.
*Various treatment options, including psychotropic medication and psychotherapy.
*Lack of a consensus opinion that sex reassignment surgery is an appropriate treatment.
*A need for further study.
Only one formal comment was received regarding the proposed amendment. The single formal comment received came from attorney Thomas Krause, plaintiff Smith's counsel in this case. Krause opposed the proposed amendment to the Iowa Administrative Rules. On December 14, 1994, the policy making body of the Iowa Department of Human Resources, the Council on Human Services, adopted the proposed amendment to the Iowa Administrative Rules which excluded sex reassignment surgery.
1. Whether sex reassignment surgery is an appropriate treatment for gender dysphoria?3
This court has considered in some detail the standards applicable to motions for summary judgment pursuant to FED.R.CIV.P. 56 in a number of recent decisions. See, e.g., Swanson v. Van Otterloo, 993 F.Supp. 1224, 1230-31 (N.D.Iowa.1998); Dirks v. J.C. Robinson Seed Co., 980 F.Supp. 1303, 1305-07 (N.D.Iowa 1997); Laird v. Stilwill, 969 F.Supp. 1167, 1172-74 (N.D.Iowa 1997); Rural Water Sys. # 1 v. City of Sioux Ctr., 967 F.Supp. 1483, 1499-1501 (N.D.Iowa 1997); Tralon Corp. v. Cedarapids, Inc., 966 F.Supp. 812, 817-18 (N.D.Iowa 1997); Security State Bank v. Firstar Bank Milwaukee, N.A., 965 F.Supp. 1237, 1239-40 (N.D.Iowa 1997); Lockhart v. Cedar Rapids Community Sch. Dist., 963 F.Supp. 805 (N.D.Iowa 1997). Thus, the court will not consider those standards in detail here. Suffice it to say that Rule 56 itself provides, in pertinent part, as follows:
Rule 56. Summary Judgment
(a) For Claimant. A party seeking to recover upon a claim, counterclaim, or cross-claim or to obtain a declaratory judgment may, at any time after the expiration of 20 days from the commencement of the action or after service of...
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