This summer, the Republican-led Iowa legislature banned the use of Medicaid funds for transition-related care after that state’s supreme court struck down a previous ban on paying for such care.

Iowa Sen. Jake Chapman argued that taxpayers shouldn’t pay for procedures that may not be medically necessary, especially compared to acute needs such as medications to keep those with Type 1 diabetes alive.

“Can you have someone say ‘I’m going bald and I have depression, so I should be eligible for hair implants [paid for by taxpayers]?’” Chapman said to Bridge.

The Republican senator said his constituents generally say the same thing:

“It’s ‘Look, I have no issue with someone having this surgery, but it should be on their dime, not taxpayers’,’” Chapman said.

The ACLU of Iowa has sued, arguing the policy is discriminatory and a “matter of life and death” since gender dysphoria — the conflict between one’s identity and their physical self — dramatically increases the risk of suicide.

Michigan state officials couldn’t provide statistics about how many gender reassignment or hormone replacement therapy procedures were covered in the state last year.

Necessary or elective?

On average, hormone replacement and one-time surgery for a transgender woman (born a male) costs about $8,518.35 in Medicaid reimbursements, while hormone replacement and one-time surgery for a transgender man (born a female) costs about $8,544.83, based on data dating to 2016, according to the state health department. These costs do not include follow-up care or expenses for complications after discharge, the department said.

VanSolkema said his surgery last spring to remove his breasts topped $30,000, a cost he said was picked up by Medicaid and disability insurance through Medicare.

The policy was clarified in Michigan with no controversy, but several conservative groups have questioned whether taxpayers should fund the procedures.

Anti-discrimination mandates and government-subsidized healthcare force some workers to take part in care that runs counter to their religious beliefs, said Peter Sprigg, a senior fellow at Family Research Council, a Washington-based fundamentalist nonprofit whose website says “homosexual conduct is harmful.”

“Ordinary health care” — tending a broken ankle, for example — “should be provided on equal terms to everyone,” Sprigg told Bridge Magazine. “Taxpayers shouldn’t be paying for a surgery that we don’t believe is medically necessary.”

Echoing that sentiment is Ryan Anderson, a senior research policy fellow for Washington, D.C.-based The Heritage Foundation, which promotes policies based on “free enterprise, limited government, individual freedom, (and) traditional American values.”

“Gender identity policies are not simply about allowing citizens who identify as transgender to be free to live how they want to — they are policies meant to coerce the rest of us,” Anderson wrote.

‘Desperately uncomfortable’

Transgender people live in a sort of awkward misalignment of reality: Their physical exterior is at odds with how they internally see themselves, said Ian Unger, youth & education manager at Affirmations, a Ferndale-based nonprofit that provides support for “people of all sexual orientations, gender identities & expressions, and cultures.”