This year has been a political roller coaster for the state’s transgender population. A March state Supreme Court decision overturned a ban on using state Medicaid dollars for transition-related surgery. Then lawmakers enacted a provision that would alter the Civil Rights Act so Medicaid could once again opt out of paying.
This has left many transgender Iowans -- who make up just 0.3 percent of the state's population -- suddenly in limbo.
Mika Covington is one of these Iowans. She was assigned the gender of male at birth, but she said she always knew something was off when she was growing up.
"I never behaved like a traditional stereotypical boy would behave with being overly sensitive," she said, "and just wasn't really interested in a lot of things that other boys were."
But it wasn’t until she moved out of rural Nebraska that she started exploring her gender identity.
"I started painting my nails, dressing more, I guess, feminine," Covington said.
Eventually through therapy, she came out as transgender, and for the past ten years, 28-year-old Covington, who also has an ultrarare genetic disorder that affects her vocal chords, has lived as a woman.
After a suicide attempt two years ago, she realized gender-affirming surgery was a matter of life or death.
"As a physician, it’s incredibly difficult to tell the patient, ‘I’m very sorry. You’ve waited so long. You’ve got the ok from the courts, and now you can’t’" - Nicole Nisly, co-director University of Iowa LGBTQ Clinic
"A lot of these emotions, this hate, this wanting to die were because of the incongruence with my gender," Covington said.
But her operation has been put on hold. Covington, who now lives in Ankeny, is on Medicaid. She was getting medical approval for the surgery this September when lawmakers introduced the last-minute provision to the health budget bill last April.
"It was a complete shock. And I sat at the table over there watching them debate this and vote on it," she said.
Covington's doctor, Nicole Nisly, is the co-director of the LGBTQ clinic at the University of Iowa, one of the few clinics that specializes in transgender health in the state.
Nisly estimates about 150 patients’ surgeries have been disrupted by the provision.
"As a physician, it’s incredibly difficult to tell the patient, ‘I’m very sorry. You’ve waited so long. You’ve got the ok from the courts, and now you can’t,’" Nisly said.
Shortly after signing the bill into law last month, Gov. Kim Reynolds stated at a press conference she wanted to return to the state’s policy of banning public funding for the procedure.
"The narrow provision that says that the Civil Rights Act does not require taxpayer dollars to go to sex reassignment and other similar services -- or surgeries," Reynolds said. "You know, that takes it back to the way it’s always been. That’s been the state’s position for a long time."
According to documents from the Department of Human Services, it is estimated that it will cost the state nearly $20 million to cover the pent-up demand for surgeries.
Several weeks earlier, Republican Sen. Mark Costello, who added the provision to the health bill, told Democratic Sen. Job Bolkcom during a Senate floor debate that he didn’t think the surgery was a proper use of state funds.
"You know it’s a pretty expensive surgery. I don’t know if I agree with you that it is always medically necessary, which is what Medicaid is about," Costello said.
But some medical organizations disagree.
A 2015 Johns Hopkins study found transition-related care was cost-effective for insurance companies because it reduced conditions like HIV, depression and drug abuse.
The American Medical Association and the American Psychiatric Association also recommend private and public insurance cover the procedure.
University of Iowa doctor Nisey says the surgery corrects gender dysphoria, which is when the disconnect between biological sex and gender identity causes extreme distress.
"A transgender person’s brain is in a different place than their body so that can cause a lot of suffering. People are being constantly misidentified," Nisly said.
A report by the Williams Institute at UCLA found that more than 40 percent of transgender people have attempted suicide.
Nisly says she’s seen firsthand how some of her patients improve after their operations.
"People [are] quitting drinking, quitting drugs, quitting smoking because again, that pain is getting better and better and is eventually no longer there," Nisly said.
In 2014, the federal government lifted a three decade ban on transitional care for Medicare after ruling it was safe and effective.
"The narrow provision that says that the Civil Rights Act does not require taxpayer dollars to go to sex reassignment and other similar services -- or surgeries" - Gov. Kim Reynolds
Iowa was one of just a handful of states that explicitly excluded transgender care under its Medicaid policy.
In Iowa, several recent court cases have ruled in favor of transgender plaintiffs seeking treatment.
Last month, a court ordered Iowa State University to pay nearly $28,000 to a transgender woman because its policy did not cover her surgery.
And in February, a jury in Polk County awarded a prison employee $120,000 after he wasn’t allowed to access to the men’s bathroom and state insurance denied his operation.
But Medicaid patients, like Covington, are still facing the unknown.
She says this is hard, knowing her rare genetic condition will shorten her lifespan.
"I worry about dying alone and not being able to share what every other human being wants," Covington said.
Last week, the ACLU filed a lawsuit challenging the narrow provision as unconstitutional. Covington’s signed on as one of the plaintiffs.
In response, Gov. Reynolds released a statement saying the state plans to defend it because that’s been the state’s position for years.
Reporter Katarina Sostaric contributed to this report.