Transgender Despite broad legalconsensus that transgender insurance exclusions are unlawful, stateand local governments continue to pursue expensive legal fights topreserve them. (Photo: Shutterstock)

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A sheriff's deputy in Perry, Ga., filed a lawsuit in federalcourt Wednesday against the county where she works over its refusalto allow her health insurance plan to cover her gender-affirmation surgery.

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Sgt. Anna Lange came out as transgender in 2017 after working inthe Houston County Sheriff's Office since 2006. She has takenhormone therapy and outwardly changed her appearance over the pastthree years to treat gender dysphoria, the distress resulting fromthe mismatch between her sex assigned at birth and her genderidentity.

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Her next step was going to be gender-affirmation surgery, butthat plan came to a halt when her insurance provider denied coverage for the procedure based on an exclusionspecified by her employer.

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Related: Industry giants come out in defense of transgenderrights

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Now, Lange is suing the Houston County Board of Commissioners toremove that exclusion. Early Wednesday, she and her lawyer, NoahLewis of the Transgender Legal Defense and Education Fund, filedsuit in U.S. District Court in Macon, Ga., alleging unlawfuldiscrimination under federal and state equal protection clauses,Title VII of the Civil Rights Act and the Americans WithDisabilities Act.

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County officials did not return calls for comment.

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Lange's case is the latest in the U.S. to challenge theexclusion of transgender care from state and municipal employeeinsurance plans ― and it could create legal precedents for casesacross the South.

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Other transgender people have won similar fights elsewhere. Themanagers of Wisconsin's state employee insurance program excluded transgender employees from coverage but later reversed that decision. Separately, two University of Wisconsinemployees sued the state and won. Another lawsuit successfully challenged transgender exclusions in Wisconsin's Medicaidplan.

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Earlier this year, Jesse Vroegh, a transgender employee of theIowa Department of Corrections, won a lawsuithe filed after being denied coverage by his employer's healthinsurance plan.

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And in Georgia, the state's university system recently settled an insurance exclusion claim forgender-affirmation surgery filed by Skyler Jay, known for hisappearance on the Netflix series "Queer Eye." In addition tochanging its employee health plan to be inclusive of transgendercare, the university system paid Jay $100,000 in damages.

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"The university clearly agreed that it was discrimination," saidLewis, who also represented Jay. "That's why they wanted to do theright thing and remove the exclusion."

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In 2011, another Georgia case, Glennv. Brumby, set the legal precedent protecting transgenderpeople from employment discrimination. However, that case did notaddress discrimination in employee benefits and, like Jay's, manyof the cases that deal with benefits have been settled out ofcourt, according to Lewis.

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The Affordable Care Act, which took effect in 2014, specificallyprohibits discrimination by health insurance issuers on the basisof gender identity, and Title VII of the Civil Rights Act has alsobeen interpreted to prohibit such discrimination.

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Despite broad legal consensus that transgender insurance exclusions are unlawful,state and local governments continue to pursue expensive legalfights to preserve them. The issue remains contentious for many social conservatives.

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"Ultimately, what's happening is that, politically, I presumethey think it's unpopular or they think they have to defend" thelaw or regulation, said John Knight, an attorney with the AmericanCivil Liberties Union.

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Resisting payment for such care can be more expensive thanproviding it. Not including the costs of state attorneys' salariesor appeals, Wisconsin's litigation against the employees of itsuniversity system cost the state more than $845,000, while Iowa'scost about $125,000.

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Furthermore, the cost of managing untreated gender dysphoria canoutweighthe costs of providing transgender-inclusive health care, accordingto a 2015 study. "Given the small number of people who actuallyneed this kind of care and the large pool of people, it will haveabsolutely no impact on the total cost of insurance for any state,"Knight said.

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While settlements like Jay's may be good for individuals, theydo not require institutions to admit wrongdoing and do not resultin a legal precedent that other, lower courts must follow.

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"The court doesn't have to look at that settlement and say, 'Oh,this was discrimination,'" said Lewis. "Transgender workers in theSouth are being left behind, which is why we're seeking a courtruling to clearly establish that this conduct is unlawfulthroughout the South."

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Lange's suit argues that the county's exclusion of transgenderhealth care from coverage was deliberate: In documents Lewisobtained under the Freedom of Information Act, Kenneth Carter, thecounty's personnel director, opted out of compliance with Section1557 of the Affordable Care Act, which prohibits discrimination byhealth programs on the basis of gender identity.

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"Houston County will be responsible for any penalties thatresult if the plan is determined to be non-compliant," he wrote ina letter to a representative of Anthem Blue Cross and Blue Shield,which administers the plan.

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Carter did not return calls for comment.

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Lange's case could end up before the 11th U.S. Circuit Court ofAppeals, yielding a decision that could influence other courts inAlabama, Florida and Georgia. And, if the ruling is in Lange'sfavor, Lewis said that would signal that transgender exclusionsshould be removed nationwide.

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In its next term, the U.S. Supreme Court will hear three casesthat will determine workplace protections of LGBTQ individuals,including one case involving a transgender woman.

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Lange said she merely wants the same protections everyone elsehas. The co-workers with whom she shares a health plan might haveused "something on the policy that I may never use or need, butit's covered," she said. "When it's finally something that I needthat one of my co-workers will probably never use or need, mine'sexcluded. And that's just not fair."

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Kaiser HealthNews (KHN) is a national health policy news service. It is aneditorially independent program of the Henry J. Kaiser Family Foundation whichis not affiliated with Kaiser Permanente.

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