Eerieanna Good and Carol Beal v. Iowa Department of Human Services , 924 N.W.2d 853 ( 2019 )

IN THE SUPREME COURT OF IOWA
No. 18–1158
Filed March 8, 2019
EERIEANNA GOOD and CAROL BEAL,
Appellees,
vs.
IOWA DEPARTMENT OF HUMAN SERVICES,
Appellant.
Appeal from the Iowa District Court for Polk County, Arthur E.
Gamble, Judge.
The Iowa Department of Human Services appeals a district court
decision striking down Iowa Administrative Code rule 441—78.1(4), which
prohibits Medicaid coverage for gender-affirming surgery. AFFIRMED.
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,
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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.
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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.
4
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.
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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.
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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
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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).
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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 primarily restores
bodily function, whether or not there is also a concomitant
improvement in physical appearance, the surgical procedure
does not fall within the provisions set forth in this subrule.
Surgeries for the purpose of sex reassignment are not
considered as restoring bodily function and are excluded from
coverage.
....
b. Cosmetic, reconstructive, or plastic surgery
performed in connection with certain conditions is specifically
excluded. These conditions are:
....
(2) Procedures related to transsexualism,
hermaphroditism, gender identity disorders, or body
dysmorphic disorders.
(3) Cosmetic, reconstructive, or plastic surgery
procedures performed primarily for psychological reasons or
as a result of the aging process.
(4) Breast augmentation mammoplasty, surgical
insertion of prosthetic testicles, penile implant procedures,
and surgeries for the purpose of sex reassignment.
....
d. Following is a partial list of cosmetic, reconstructive,
or plastic surgery procedures which are not covered under the
program. This list is for example purposes only and is not
considered all-inclusive.
....
(2) Cosmetic, reconstructive, or plastic surgical
procedures which are justified primarily on the basis of a
psychological or psychiatric need.
....
(15) Sex reassignment.
Iowa Admin. Code r. 441—78.1(4)(b)(2)–(4), (d)(2), (15) (emphasis added).
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Good filed her request for Medicaid preapproval from AmeriHealth
to cover the expenses of her gender-affirming surgical procedure on
January 27, 2017. AmeriHealth denied Good’s request based on the rule
excluding any surgical procedure for the purpose of sex reassignment.
Good initiated an internal appeal, which AmeriHealth also denied. Good
subsequently appealed AmeriHealth’s denial of her preapproval request to
cover the expenses of her gender-affirming surgery to the DHS. The
administrative law judge (ALJ) preserved Good’s constitutional challenge
to the rule excluding coverage for gender-affirming surgery and affirmed
AmeriHealth’s decision, noting the rule prohibited coverage for Good’s
requested procedure. Good appealed the ALJ decision to the director of
the DHS, who adopted the ALJ’s decision and determined the DHS lacked
jurisdiction to review Good’s constitutional challenge to the rule.
Good filed a petition for judicial review in district court on
September 21, arguing Iowa Administrative Code rule 441—78.1(4)
violates the ICRA’s prohibitions against sex and gender identity
discrimination and the equal protection clause of the Iowa Constitution.
She also claimed the DHS’s application of the rule creates a
disproportionate negative impact on private rights and is arbitrary and
capricious. The DHS filed a preanswer motion to dismiss for failure to
state a claim upon which relief can be granted, which the district court
denied on November 27.
Beal filed her request for Medicaid preapproval from Amerigroup to
cover the expenses of her gender-affirming surgical procedures on June 8.
Amerigroup denied Beal’s request based on the rule excluding surgical
procedures for the purpose of sex reassignment. Beal initiated an internal
appeal, which Amerigroup also denied. Beal subsequently appealed
Amerigroup’s denial of her preapproval request to cover the expenses of
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her gender-affirming surgery to the DHS. The ALJ preserved Good’s
constitutional challenges to the rule excluding coverage for gender-
affirming surgery and affirmed Amerigroup’s decision, noting the rule
prohibited coverage for Beal’s requested procedures. Beal appealed the
ALJ decision to the director of the DHS, who adopted the ALJ’s decision
and determined the DHS lacked jurisdiction to review Beal’s constitutional
challenge to the rule.
Beal filed a petition for judicial review in district court on
December 15 presenting the same arguments as Good. The DHS also filed
a motion to dismiss on Beal’s case, claiming Beal failed to state a claim
upon which relief can be granted. The district court denied this motion
and consolidated Good’s case with Beal’s case on January 26, 2018.
Following briefing on the merits and a hearing, the district court
reversed the DHS’s decision to deny Good and Beal Medicaid coverage for
their gender-affirming surgical procedures. The district court concluded
the DHS is a public accommodation under the ICRA, and rule 441—
78.1(4), which denies coverage for gender-affirming surgeries, violates the
ICRA’s prohibition on gender-identity discrimination. However, the
district court rejected appellees’ claim that the rule also violates the ICRA’s
prohibition on sex discrimination, relying on our holding in Sommers v.
Iowa Civil Rights Commission, which held that sex discrimination under
the ICRA does not include “transsexuals.” 337 N.W.2d 470, 474 (Iowa
1983). The district court also concluded rule 441—78.1(4) violates the
equal protection clause of the Iowa Constitution. Moreover, the district
court determined the DHS’s decision to enforce rule 441—78.1(4) should
be reversed because it had a grossly disproportionate negative impact on
private rights and was arbitrary and capricious. The DHS appealed the
district court ruling, and we retained the appeal.
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II. Standard of Review.
“Iowa Code section 17A.19 governs judicial review of this agency
action.” Cox v. Iowa Dep’t of Human Servs., 920 N.W.2d 545, 549 (Iowa
2018); see also Iowa Code § 17A.19. “We apply the standards set forth in
Iowa Code chapter 17A in our judicial review of agency decision-making to
determine whether our conclusion is the same as the district court.”
Brewer-Strong v. HNI Corp., 913 N.W.2d 235, 242 (Iowa 2018). It is proper
for a district court to grant relief “if the agency action prejudiced the
substantial rights of the petitioner and if the agency action falls within one
of the criteria listed in section 17A.19(10)(a) through (n).” Id. (quoting
Brakke v. Iowa Dep’t of Nat. Res., 897 N.W.2d 522, 530 (Iowa 2017)). The
burden is on the party challenging the agency action. Hawkeye Land Co.
v. Iowa Utils. Bd., 847 N.W.2d 199, 207 (Iowa 2014). “We affirm the district
court decision when we reach the same conclusion.” Brewer-Strong, 913
N.W.2d at 242. “Although the DHS is the state agency administering
Medicaid benefits, we decline to give deference to the DHS interpretation
of the [Medicaid] Act and the DHS’s rules and regulations regarding
Medicaid.” Cox, 920 N.W.2d at 549. Thus, we review the DHS’s
interpretation of the law de novo. See Bearinger v. Iowa Dep’t of Transp.,
844 N.W.2d 104, 106 (Iowa 2014).
III. Analysis.
The DHS raises several challenges to the district court’s ruling on
appeal. First, the DHS argues it is not a public accommodation under the
ICRA. Second, the DHS maintains rule 441—78.1(4) does not violate the
ICRA. Third, the DHS claims rule 441—78.1(4) does not violate the equal
protection clause of the Iowa Constitution. Fourth, the DHS contends the
district court erred in reversing the DHS’s decision based on its finding
that rule 441—78.1(4) had a disproportionate negative impact on private
12
rights. Finally, the DHS challenges the district court ruling that rule 441—
78.1(4) is arbitrary and capricious. We address these claims as necessary.
A. Public Accommodations Under the ICRA. Iowa Code section
216.7 addresses “[u]nfair practices—accommodations or services.” In
relevant part, this section provides,
It shall be an unfair or discriminatory practice for any . . .
manager . . . of any public accommodation or any agent or
employee thereof . . . [t]o refuse or deny any person because
of . . .sex . . . [or] gender identity . . . in the furnishing of such
accommodations, advantages, facilities, services, or
privileges.
Iowa Code § 216.7(1)(a). Iowa Code section 216.2(13)(b) states that a
public accommodation “includes each state and local government unit or
tax-supported district of whatever kind, nature, or class that offers
services, facilities, benefits, grants, or goods to the public, gratuitously or
otherwise.” Id. § 216.2(13)(b). The DHS challenges the district court’s
conclusion that it is a “public accommodation.” It asserts that the term is
limited to physical places, establishments, or facilities.
The ICRA does not define “government unit.” “If the legislature has
not defined words of a statute, we may refer to prior decisions of this court
and others, similar statutes, dictionary definitions, and common usage.”
State v. Romer, 832 N.W.2d 169, 179 (Iowa 2013) (quoting Jack v. P & A
Farms, Ltd., 822 N.W.2d 511, 516 (Iowa 2012)). Further, “[a]lthough the
title of a statute cannot limit the plain meaning of the text, it can be
considered in determining legislative intent.” State v. Tague, 676 N.W.2d
197, 201 (quoting T & K Roofing Co. v. Iowa Dep’t of Educ., 593 N.W.2d
159, 163 (Iowa 1999)). Here, our prior decisions, dictionary definitions,
and the title of the statute prohibiting public accommodations from certain
types of discrimination under the ICRA all support our conclusion that the
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DHS is a “government unit” within the ICRA’s definition of a “public
accommodation.”
Our prior cases discussing a “government unit” are limited, but our
past use of the term supports our interpretation that public
accommodations are not limited to a physical place, establishment, or
facility. For example, in Warford v. Des Moines Metropolitan Transit
Authority, we noted Iowa’s statute governing tort liability of governmental
subdivisions “anticipates that a ‘municipality’ will be some unit of local
government.” 381 N.W.2d 622, 624 (Iowa 1986). Further, the dictionary
definitions of “unit” reinforce our holding that the DHS is a “government
unit” within the ICRA’s definition of a “public accommodation” when it
issues benefits determinations concerning Medicaid. Though the
dictionary has multiple definitions for the word “unit,” the most applicable
definition of “unit” defines it as “a single thing or person or group that is a
constituent and isolable member of some more inclusive whole.” Unit,
Webster’s Third New International Dictionary (unabr. ed. 2002). This
definition aligns with the Black’s Law Dictionary definition of
“governmental unit” as “[a] subdivision, agency, department . . . or other
unity of government of a country or state” because the DHS is a
government agency. Governmental Unit, Black’s Law Dictionary (10th ed.
2014) (emphasis added).
Additionally, Iowa Code section 216.2(13)(b) makes clear that a
“public accommodation” includes a unit of state government that offers
“benefits [or] grants . . . to the public.” Medicaid is such a benefit or grant.
Government benefits and grants are not normally dispersed in person at
physical locations. This further undermines the DHS’s limited view of
what constitutes a public accommodation under the ICRA.
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The title of the statute Good and Beal rest their ICRA claims on—
“Unfair practices—accommodations or services”—also informs our
determination that the legislature intended to include the DHS as a “public
accommodation” under the ICRA. See Iowa Code § 216.7. The title of this
section and its definition of a “public accommodation” reveal the
legislature intended to include government agencies in its prohibition on
discriminatory practices based on gender identity “in the furnishing of [an
agency’s] accommodations, advantages, facilities, services, or privileges.”
See id. § 216.7(1)(a). The DHS is an agency that furnishes Medicaid
services through its implementation and oversight of the Iowa Medicaid
services that MCOs provide. Therefore, it is a public accommodation
under the ICRA.
Finally, while the ICRA does define “covered multifamily” as “[a]
building consisting of four or more dwelling units if the building has one
or more elevators” or “the ground floor units of a building consisting of four
or more dwelling units,” this usage of “unit” does not conflict with our
interpretation of it in section 216.7 as the DHS claims. Iowa Code
§ 216.2(4) (emphasis added.) The use of the term “unit” to describe a
“covered multifamily dwelling” is vastly different from the use of
“government unit” within the definition of “public accommodation” given
the context in which both terms are used. Thus, the legislature’s
references to the word “unit” to describe a structure does not inform or
limit our definition of “government unit.” For these reasons, we affirm the
district court’s ruling that the DHS is a public accommodation under the
ICRA.
B. The ICRA’s Prohibition on Gender Discrimination. The DHS
maintains rule 441—78.1(4) does not discriminate based on gender
identity because transgender Medicaid beneficiaries and nontransgender
15
Medicaid beneficiaries in Iowa alike are not entitled to gender-affirming
surgical procedures. This position is based on the DHS’s argument that
the requested surgical procedures are performed primarily for
psychological purposes. Further, the DHS claims the rule’s explicit
exclusion of gender-affirming surgeries and cosmetic surgery related to
“transsexualism” is merely a specified example within the broader category
of “cosmetic, reconstructive, and plastic surgeries” excluded from coverage
under the rule.
In 2007, the Iowa legislature amended the ICRA to add “gender
identity” to the list of protected groups. See 2007 Iowa Acts ch. 191, §§ 5,
6 (codified at Iowa Code § 216.7(1)(a) (2009)). Section 216.7(1)(a) provides
that it is “unfair or discriminatory” for any “agent or employee” of a “public
accommodation” to deny services based on “gender identity.” Iowa Code
§ 216.7(1)(a). The ICRA’s gender identity classification encompasses
transgender individuals—especially those who have gender dysphoria—
because discrimination against these individuals is based on the
nonconformity between their gender identity and biological sex. This
prohibition against denying coverage for Good’s and Beal’s gender-
affirming surgical procedures extends to the director and staff of the DHS,
as well as its agents, the MCOs.
The record does not support the DHS’s position that rule 441—
78.1(4) is nondiscriminatory because its exclusion of coverage for gender-
affirming surgical procedures encompasses the broader category of
“cosmetic, reconstructive, or plastic surgery” that is “performed primarily
for psychological purposes.” Iowa Admin. Code r. 441—78.1(4). The DHS
expressly denied Good and Beal coverage for their surgical procedures
because they were “related to transsexualism . . . [or] gender identity
disorders” and “for the purpose of sex reassignment.” Id. r. 441—
 16
78.1(4)(b). Moreover, the rule authorizes payment for some cosmetic,
reconstructive, and plastic surgeries that serve psychological purposes—
e.g., “[r]evision of disfiguring and extensive scars resulting from neoplastic
surgery” and “[c]orrection of a congenital anomaly.” Id. r. 441—78.1(4)(a).
Yet, it prohibits coverage for this same procedure if a transgender
individual. Id. r. 441—78.1(4)(b).
Further, the history behind the rule supports our holding that the
rule’s express bar on Medicaid coverage for gender-affirming surgical
procedures discriminates against transgender Medicaid recipients in Iowa
under the ICRA. Nearly forty years ago, the United States Court of Appeals
for the Eighth Circuit ruled in Pinneke v. Preisser that it was improper for
the Iowa DHS to informally characterize sex reassignment surgery as
“cosmetic surgery” in its denial of sex reassignment surgery. 623 F.2d
546, 548 n.2 (8th Cir. 1980). Prior to Pinneke, the DHS had an unwritten
policy of excluding sex reassignment surgeries from Medicaid coverage
based on Medicaid’s coverage limitations on “cosmetic surgery” and
“mental diseases.” Id. at 548 n.2, 549–50. After the Eighth Circuit rejected
this informal policy, the DHS amended the rule to clarify that the rule
excluded Medicaid coverage for “sex reassignment procedures” and
“gender identity disorders.” 17 Iowa Admin. Bull. 730–34 (Nov. 9, 1994)
(effective Feb. 1, 1995); see also Smith v. Rasmussen, 249 F.3d 755, 760
(8th Cir. 2001). Consequently, the rule expressly excludes Iowa Medicaid
coverage for gender-affirming surgery specifically because this surgery
treats gender dysphoria of transgender individuals. After the DHS
amended the rule to bar Medicaid coverage for gender-affirming surgery,
the legislature specifically made it clear that individuals cannot be
discriminated against on the basis of gender identity under the ICRA. See
2007 Iowa Acts ch. 191, §§ 5, 6 (codified at Iowa Code § 216.7(1)(a) (2009)).
17
C. Doctrine of Constitutional Avoidance. Given our holding that
rule 441—78.1(4)’s exclusion of Medicaid coverage for gender-affirming
surgery violates the ICRA as amended by the legislature in 2007, we need
not address the other issues raised on appeal. In doing so, we adhere to
the time-honored doctrine of constitutional avoidance. See, e.g., Hawkeye
Land Co. v. Iowa Utils. Bd., 847 N.W.2d 199, 219 (Iowa 2014); State v. Iowa
Dist. Ct., 843 N.W.2d 76, 85 (Iowa 2014); Mail Real Estate, LLC v. City of
Hamburg, 818 N.W.2d 190, 200 (Iowa 2012); L.F. Noll Inc. v. Eviglo, 816
N.W.2d 391, 398 (Iowa 2012); Simmons v. State Pub. Def., 791 N.W.2d 69,
73‒74 (Iowa 2010). This doctrine “instructs us that we should ‘steer clear
of “constitutional shoals” when possible.’ ” Nguyen v. State, 878 N.W.2d
744, 751 (Iowa 2016) (quoting Iowa Dist. Ct., 843 N.W.2d at 85). “Such
judicial restraint is an essential component of our system of federalism
and separation of powers.” State v. Williams, 695 N.W.2d 23, 30 (Iowa
2005). The doctrine of constitutional avoidance recognizes the wisdom of
this process, “and we continue to subscribe to it today.” Id.
IV. Conclusion.
For the aforementioned reasons, we affirm the district court
judgment.
AFFIRMED.
All justices concur except McDonald, J., who takes no part.