A federal court in Georgia ruled Thursday that employers who categorically exclude gender-affirming medical care from health insurance coverage violate federal law.
Anna Lange, a transgender woman and sheriff’s deputy in Houston County, Georgia, sued in 2019 after she was denied coverage for a vaginoplasty in November 2018.
The Sheriff's Office provides health care coverage to employees through the county plan, which, beginning in 1998, excluded coverage for talk therapy related to gender dysphoria, gender-affirming hormone therapy and gender-affirming surgeries, according to the opinion released Thursday.
Chief Judge Marc Treadwell, of the U.S. District Court for the Middle District of Georgia, wrote in the opinion that the exclusion "plainly discriminates because of transgender status," and as a result violates Title VII of the Civil Rights Act of 1964, a federal law that prohibits employment discrimination based on race, sex, religion, national origin and other protected categories.
He pointed to evidence that showed Houston County's health care plan, provided through Anthem Blue Cross and Blue Shield, would provide hormone therapy for menopause and surgery for breast cancer, but it would not provide the same procedures as treatment for gender dysphoria.
"The undisputed, ultimate point is that the Exclusion applies only to transgender members, and it applies to Lange because she is transgender," Treadwell wrote, citing a landmark Supreme Court decision in June 2020, which found that Title VII's protection from discrimination based on sex also includes gender identity and sexual orientation discrimination.
The opinion also noted that, in 2016, Houston County's insurance broker, who acted as a liaison between the county and Anthem, informed the county that Anthem would no longer categorically exclude coverage for treatments related to gender dysphoria as a result of the Affordable Care Act's Section 1557, which prohibits discrimination based on sex and other characteristics.
"Despite Anthem’s recommendation to do so, the County chose not to accept the nondiscrimination mandate," according to the opinion.
A representative for Houston County did not immediately return a request for comment.
Lange, who was represented in part by the Transgender Legal Defense and Education Fund, said in a statement that it's "a huge relief to know that I can finally receive the medically necessary care that I was repeatedly and unfairly denied.”
“I can confidently move forward with my life knowing that gender affirming care is protected under federal law," she said. "This decision is not only a personal victory, but a tremendous step forward for all transgender Southerners who are seeking insurance coverage for medically necessary care.”
David Brown, the legal director for the Transgender Legal Defense and Education Fund, said the court's decision “makes clear that depriving transgender people of health care is not only immoral but also illegal.”
“An employer cannot refuse health coverage to a transgender employee who needs access to medically necessary, life-saving care," he said. "This ruling will have transformative impact on the quality of life for countless transgender people who live in the South.”
A report last year from the Center for American Progress, a liberal think tank, found that many transgender people report facing insurance barriers to care. Forty percent of transgender respondents — and 56 percent of trans respondents of color — said their health insurance companies denied coverage for gender-affirming care, which includes treatments like hormones and surgery. The report also found that 48 percent of trans respondents, including 54 percent of trans respondents of color, said their health insurance companies covered only some gender-affirming care or had no providers in network.
State laws regulating coverage for transition-related care vary widely. Twenty-four states and Washington, D.C., prohibit transgender exclusions in health insurance coverage, according to the Movement Advancement Project, a nonprofit think tank. Twenty-four states, one territory and Washington, D.C., have Medicaid policies that explicitly cover transition care for transgender people.
The remaining states have a mix of policies: Some don’t have any Medicaid policy that explicitly covers transgender care, 10 states have Medicaid policies that explicitly exclude trans health coverage and care, and one state — Arkansas — allows all insurers in the state to refuse to cover gender-affirming care.
In the last year, some Republican state leaders have tried to curtail access to gender-affirming medical care in other ways. For example, governors in Arkansas, Tennessee and Alabama have signed measures that ban access to certain transition-related care for minors, and Florida Gov. Ron DeSantis' administration on Thursday moved to restrict care for minors and for trans people of all ages on Medicaid.
But an increasing number of courts have ruled in favor of transgender people who sue for coverage. In September, the 4th U.S. Circuit Court of Appeals ruled that trans people who are enrolled in the North Carolina State Health Plan can sue over the state’s 2018 policy that excludes all coverage for gender dysphoria counseling, hormone therapy, surgical care and other treatment.
Then, in November, an Iowa judge ruled that a law prohibiting Medicaid coverage for gender-affirming surgeries violated state law and the state Constitution.
Some health insurance companies have also updated their policies over the years. For example, Blue Cross and Blue Shield of North Carolina changed its policies last July to include coverage for gender-affirming facial surgery and voice therapy as medically necessary care.