CREDIT: Flickr/J. Stephen Conn

Medically necessary coverage turns out to be legally necessary too.

A Minnesota state judge has issued a ruling that is good news for the state’s transgender community. After an 11-year ban, the state’s Medicaid system, known as Medical Assistance (MA) must provide coverage for transition-related surgical procedures.

A 64-year-old trans man by the name of Evan Thomas sued, with support from the ACLU of Minnesota and OutFront Minnesota, for the right to a double mastectomy. His doctors deemed the procedure medically necessary for resolving his gender dysphoria, but Thomas depended on MA, which denied him coverage. In the meantime, Thomas was relying on chest binding to help resolve his dysphoria, but he had to stop after it caused him chest infections and acute bronchitis.

Ramsey County Judge William Leary concluded that the 2005 state law prohibiting that coverage is unconstitutionally discriminatory. His opinion effectively outlines the medical consensus on transgender care and the benefits of gender reassignment surgery, noting that the state covers double mastectomies for patients with other concerns but singles out transgender individuals for denial. He also outlines the history of state lawmakers’ efforts to prohibit such coverage.

The Minnesota Supreme Court actually ruled way back in 1977 that MA must cover surgical treatment for trans people. In 1994, the state legislature tried to pass a law banning state medical coverage of surgeries, but it failed. In 1998, it successfully passed a restriction on MA coverage, but it included a grandfather clause that allowed individuals who had already started hormone treatment to still qualify for surgical coverage. Then in 2005, the legislature eliminated the grandfather clause, banning surgical coverage for everybody.

This legislative history contributed to Leary’s conclusion that there was clear discriminatory intent. None of these restrictions included any legislative statements explaining the purpose or rationale of the statutes. He was also not swayed by the possibility that the restrictions were important for saving the state money:

Any argument that the statute is justified because it “saves money” relies on illegitimate means to achieve that purpose. It deprives a small class of individuals, admittedly the subject of every conceivable form of discrimination, from medically necessary treatment for the assumed purpose of saving a de minimis portion of the state budget. To assume that such a distinction is [anything] other than “arbitrary and capricious” is to ignore the right to equal protection under the law.

The estimated cost for covering the surgeries in fiscal year 2017 is $130,000 (three surgeries), compared to a total of $17,146,040,000 the state expects to spend on Health and Human Services.

The decision provides an extra layer of security to the state’s transgender community in the wake of Donald Trump’s election. The state Department of Human Services (DHS) tried to argue that the prohibition was moot because a new federal regulation under the Affordable Care Act would require the state to cover surgeries in January anyway. Leary pointed out that not only did that do little to address Thomas’ immediate medical needs, but there was no guarantee that the regulation would remain in place.

The Department confirmed Wednesday that it accepts the decision and will provide the coverage in compliance with both the ruling and the federal rule.