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Federal Court Awards Significant Damages to Individuals Denied Plastic Surgery Because of HIV Status 

Posted on: August 22nd, 2020 by Art Leonard No Comments

U.S. District Judge Analisa Torres (S.D.N.Y.) ruled on August 5 in United States v. Asare, 2020 U.S. Dist. LEXIS 139864, that three men who were denied plastic surgery by Dr. Emmanuel O. Asare because he believed them to be HIV-positive are entitled to the maximum statutory damages available in such a case under the Americans With Disabilities Act and the New York City Human Rights Law.  The court ordered that Dr. Asare to pay each of the men $125,000 and to pay a fine to the government of $15,000.  The total awarded is $390,000 in damages and penalties.  The court also ordered Dr. Asare to refrain from testing patients for HIV as a prerequisite for denying them services if they test positive.

The U.S. Department of Justice, which enforces Title III of the Americans with Disabilities Act (ADA), forbidding unjustified disability discrimination by public accommodations (including medical practices), filed this lawsuit in 2015, consolidating in one case complaints by three New York men, Mark Milano, J.G., and S.V.  Each of the men had gone to Dr. Asare seeking a procedure to remove unwanted body fat from their chests, a common procedure in which the doctor specialized.  Each of the men was ultimately rejected for the procedure by the doctor when he came to believe (incorrectly in the case of one of them) that they were HIV-positive.

According to the court’s findings after discovery and trial, Dr. Asare’s practice was to have blood drawn for testing some days in advance of the scheduled procedure, to determine whether the patient had any condition that would cause him to deny them treatment.  J.G. and S.V. both testified that they were not asked to consent to HIV testing and were not aware that their blood would be tested for this purpose.  Dr. Asare’s practice was to categorically refuse to perform plastic surgery on HIV-positive people in his clinic.

J.G. had been scheduled for the procedure, but received a call from Dr. Asare’s office asking him to come in to speak with the doctor, who informed him that he had tested positive for HIV and could not receive the procedure.  J.G. had known for years that he was HIV-positive but had not disclosed this on the doctor’s intake questionnaire because he had long kept this information secret from all but a handful of individuals.  He was on anti-retroviral therapy, with an undetectable viral load, and was otherwise healthy.  When he submitted to a blood draw for testing, he was not told that his blood would be tested for HIV.

S.V., a single father of two children who was planning to get married, decided to get the surgical procedure because he was dissatisfied by the appearance of his body.  Due to some sort of mix-up, he had actually reported for the procedure, was sedated and ready for it to be performed, when Dr. Asare informed him that the blood draw a few days earlier showed that he was HIV-positive and the procedure was off.   Asare called a car service for S.V. and sent him home in a sedated state!  When he arrived home, S.V., who was puzzled and shocked by the news, was so woozy that he had to crawl up the stairs to his bedroom and slept for hours.  Not believing that he could possibly be HIV-positive, he went to a hospital a few days later for testing and was informed that he was not HIV-positive.  Judge Torres’ opinion identifies J.G. and Milano as gay men, but does not so specify as to S.V., and does not mention the gender of the person he was planning to marry.

Mark Milano, who was working at the time for an HIV/AIDS organization, also knew that he was HIV-positive, but he did not indicate this on the intake questionnaire because he did not consider the information relevant.  However, in discussing the procedure with Dr. Asare, he asked out of curiosity whether the anti-viral medication he was taking could be responsible for the fatty deposits he wanted to have removed from his chest.  Asare replied that his office was not set up to provide surgery for HIV-positive people and refused to schedule the procedure.  Thus, with Milano things did not get to the stage of blood testing in advance of the procedure.

Under the ADA, a public accommodation, including a medical practice, may not deny services to somebody because of a disability, either actual or perceived, unless the disability renders the person unqualified for the service.  In this case, Judge Torres heard expert testimony that convinced her that being HIV-positive, which is considered a disability under the ADA, was not a disqualification for the procedure Dr. Asare was supposed to provide to these men.  She concluded that the doctor’s explanation that it would be dangerous to mix the anesthetic he used with the anti-retroviral medication that an HIV-positive person would be taking had no medical basis.

Furthermore, the ADA prohibits medical testing that would unjustifiably screen out qualified individuals from receiving a service.  The medical experts testified that all surgeons are supposed to observe “universal precautions” with patients to avoid exposure to any blood-borne infections, regardless of testing.  The emergence of “universal precautions” as the standard of care was actually sparked by the AIDS epidemic.  Before then, it was an open secret in the medical profession that many health care professionals were infected with hepatitis B, a much more easily transmitted infection through blood exposure than HIV, as a result of casual exposure to the blood of patients in health care facilities where universal precautions against such exposure were not enforced.

Thus, Dr. Asare was found to have violated the ADA (and, since his activities were taking place in New York City, the City’s Human Rights Law) in two respects: denying services to people with a disability, and using medical testing to screen out otherwise qualified people with a disability.

Some of these points had been established at earlier stages of the litigation when the focus was on Mr. Milano’s discrimination claim.  The government’s decision to add claims on behalf of J.G. and S.V. prolonged the case, because the issue of testing, which was not raised in Milano’s case, had to be addressed in connection with J.G. and S.V..  The court needed medical expert testimony so that Judge Torres could determine whether requiring the testing violated the statute, a crucial point in framing her remedial order in the case, and haggling about the qualification of an appropriate expert caused significant delay, which is one of the reasons a lawsuit originally filed in 2015 did not come to a final ruling by the trial court until five years later.

The amount of damages was determined by reference to the range of damages that are customarily awarded in Title III cases.  Here the focus was on the psychological and emotional impact on the three men from being denied Dr. Asare’s services under these circumstances.  Each of them credibly testified about severe emotional distress that they suffered, prompting the judge to award the highest amount of damages that she found to be available under the ranges of damages that have been awarded in ADA cases, adding consideration of the range of remedies available under the New York City law as well.

It is possible that Dr. Asare could get the damages cut down on appeal to the 2nd Circuit Court of Appeals, but Judge Torres devoted a substantial part of her opinion to describing the testimony about how each man was affected by being rejected for the procedure, and particularly the bizarre treatment of S.V., who was not HIV-positive and was actually prepped for surgery and sedated by mistake, then sent home in that sedated state without any supervision or follow-up from Dr. Asare’s office to see whether he was all right.  The court’s description of Dr. Asare’s conduct in this case should draw the attention of regulatory authorities on health care practice.

Lawyers from the U.S. Department of Justice prosecuted the case against Dr. Asare, but Mark Milano was allowed by Judge Torres to intervene as a co-plaintiff, and he was represented by Alison Ellis Frick and Matthew D. Brinckerhoff, of Emery Celli Brinckerhoff & Abady, LLP, New York, NY, as well as Armen Hagop Merjian, who has litigated many important HIV-related cases on behalf of Housing Works, Inc., a provider of housing to people living with HIV and an active advocate for their rights.

Federal Court Blocks Trump Regulation Revoking Health Care Protections for Transgender People

Posted on: August 18th, 2020 by Art Leonard No Comments

U.S. District Judge Frederic Block ruled on August 17 that a new Trump Administration Rule that rescinded the Obama Administration’s Rule prohibiting gender identity discrimination in health care will not go into effect on August 18, its scheduled date, and he granted a preliminary injunction against the new Rule’s enforcement.  Judge Block sits in the U.S. District Court for the Eastern District of New York, in Brooklyn. Walker v. Azar, 2020 U.S. Dist. LEXIS 148141.

After President Obama signed the Affordable Care Act (ACA) into law in 2010, the Department of Health and Human Services (HHS) decided to adopt a rule providing an official interpretation of the non-discrimination requirements contained in Section 1557 of that statute.  Section 1557 incorporates by reference a provision of Title IX of the Education Amendments of 1972, which forbids discrimination because of sex in educational institutions that get federal funding.  In the past, HHS and federal courts have looked to decisions interpreting the sex discrimination provision in Title VII of the Civil Rights Act of 1964, which bans sex discrimination in employment, in interpreting Title IX.

By the time HHS had finished writing its rule in 2016, both the Equal Employment Opportunity Commission and several federal appeals courts had interpreted Title VII to ban discrimination because of an individual’s gender identity.  The Obama Administration followed these precedents and included a prohibition on gender identity discrimination in its ACA rule.  Several states and a religious health care institution then joined together to challenge the rule before a federal district judge in Fort Worth, Texas, who was notoriously receptive to issuing nationwide injunctions against Obama Administration policies, and the court was true to that practice, holding that the inclusion of gender identity was contrary to the “original meaning” of the term “because of sex” when it was adopted by Congress in Title IX back in 1972.  The case is Franciscan Alliance, Inc. v. Burwell, 227 F. Supp. 3d 660 (N.D. Tex. 2016).

The new Trump Administration rule that was challenged in the August 17 ruling was intended by the Department of Health and Human Services to codify the decision by district court in Franciscan Alliance.  Franciscan Alliance was issued in December 2016, just weeks before the Trump Administration took office.  Had Hillary Clinton been elected president, the incoming administration would likely have appealed the Fort Worth decision to the U.S. Court of Appeals for the 5th Circuit. But the Trump Administration informed the district court that it was not appealing and instead would not enforce the Obama Administration rule and would eventually replace it.

Judge Block emphasized this history as he set out his reasons for finding that Human Rights Campaign (HRC) and its volunteer attorneys from Baker & Hostetler LLP, were likely to succeed on the merits of their claim that the Trump Rule was both inconsistent with the ACA, and that HHS was “arbitrary and capricious” in adopting this new Rule and publishing it just days after the Supreme Court had ruled in Bostock v. Clayton County that discrimination against a person because of their transgender status was “necessarily discrimination because of sex.”

The Supreme Court had heard oral arguments in the Bostock case, which concerned the interpretation of Title VII, on October 8, 2019, while HHS was working on its proposed new rule.  The HHS attorneys knew that the Supreme Court would be issuing a decision by the end of its term, most likely in June 2020.  One of the three cases consolidated in Bostock involved a gender identity discrimination claim by Aimee Stephens against Harris Funeral Homes. The Equal Employment Opportunity Commission (EEOC) had sued the employer on Stephens’ behalf.  The 6th Circuit Court of Appeals ruled that Harris Funeral Homes violated Title VII by discharging Stephens for transitioning, and the Supreme Court granted review on the specific question whether discrimination because of transgender status violates Title VII.  HHS concedes in the “preamble” of its new rule that interpretations of Title IX (and thus Section 1157) generally follow interpretations of Title VII.

October 2017, then-Attorney General Jeff Sessions issued a memorandum to the Executive Branch explaining the Trump Administration’s position that bans on sex discrimination in federal law did not extend to claims of discrimination because of sexual orientation or gender identity.  Thus, although the U.S. Solicitor General normally represents federal agencies such as the EEOC when their decisions are appealed to the Supreme Court, that office actually joined in  arguing on behalf of Harris Funeral Homes, leaving it to the ACLU LGBT Rights Project to represent Aimee Stephens before the Supreme Court.

The Trump Administration was so confident that the Court would rule against Stephens that it decided to go ahead with its new Rule, effectively revoking the Obama Administration’s Rule, although the “preamble” did acknowledge that a decision by the Supreme Court in the Title VII case could affect the interpretation of Section 1557.  LGBTQ rights advocates waited impatiently for a ruling in the Bostock case as the Court began to wind up its Term in June.  The Trump Administration was no more patient, announcing its new Rule a few days before the Supreme Court announced its decision in Bostock, apparently assuming that the Court would rule against Stephens.  Without publicly reacting to the Supreme Court’s opinion, or even revising its new Rule to acknowledge that the Trump Administration’s interpretation of “discrimination because of sex” had been rejected by the Supreme Court (in an opinion by Trump’s first appointee to the Court, Justice Neil Gorsuch), HHS went ahead and published the new Rule five days later.

Over the following weeks, challenges to the new Rule were filed in four different federal courts.  HRC filed suit on behalf of two transgender women who had encountered discrimination from health care institutions covered by the ACA.  Judge Block found that their experiences gave them formal standing to challenge the new Rule. Judge Block reached his decision the day before the new Rule was to go into effect.

He found that the well established practice of following Title VII interpretations in sex discrimination cases was likely to be followed under the ACA, just as it was under Title IX, and thus the plaintiffs were likely to succeed in their claim that the new Rule was inconsistent with  the statute.  He noted that just two weeks earlier, the 11th Circuit Court of Appeals had followed the Bostock decision in finding that a Florida school district violated Title IX by denying appropriate restroom access to a transgender student.

Furthermore, the failure of the new rule, published after the Bostock decision, to mention that ruling or to offer any reasoned explanation why it should not be followed, was likely to be found to be “arbitrary and capricious,” so the adoption of the new Rule probably violated the Administrative Procedure Act (APA), the federal law that details how federal agencies are to proceed in adopting new rules and regulations or rescinding old ones.

Because of the December 2016 ruling in Franciscan Alliance and the subsequent non-enforcement policy by the Trump Administration, the Obama Administration’s Rule has not been enforced by HHS since December 2016.  But the ACA allows individuals who suffer discrimination to sue on  their own behalf to enforce the statute, and there have been numerous lawsuits under Section 1557 successfully challenging exclusion of transgender health care from coverage under health insurance policies that are subject to the ACA.

Judge Block’s stay of the effective date and injunction against enforcing the new Rule gives the green light to HHS to resume enforcing Section 1557 in gender identity discrimination cases consistent with the Bostock ruling.  While there are probably plenty of career agency officials in the HHS Office of Civil Rights who would like to do so, any significant effort in that direction seems unlikely so long as Trump remains in office.  For now, the main impact of Judge Block’s order will be to clear a potential obstacle for transgender litigants under Section 1557, as the opinion persuasively explains how Justice Gorsuch’s reasoning in Bostock compels protecting transgender health care patients under the ACA.

The  practical effect of Judge Block’s ruling now is to place the burden on HHS if it wants to  continue defending its new Rule.  HHS must provide a reasoned explanation to the Court about why the Bostock interpretation of “discrimination because of sex” should not be followed under Section 1557.  The simplest way for HHS to proceed consistent with the court’s order would be to strike those portions of the preamble discussing this subject, and to substitute a simple statement that Section 1557’s ban on discrimination because of sex includes claims of discrimination because of sexual orientation  or gender identity consistent with  the U.S. Supreme Court’s interpretation of similar statutory language in the Bostock case.

Federal Judge Voids Tampa Ban on Conversion Therapy

Posted on: October 18th, 2019 by Art Leonard No Comments

U.S. District Judge William F. Jung ruled on October 4 in Vazzo v. City of Tampa, 2019 U.S. Dist. LEXIS 172734, 2019 WL 4919302 (M.D. Fla.), that the state of Florida’s pervasive regulation of professional health care deprives the city of Tampa from the authority to impose sanctions on licensed health care workers who perform “conversion therapy” on minors.

Jung’s ruling was a startling departure from the way most courts have responded to challenges against laws cracking down on the charlatans who engage in this discredited practice.  Several federal courts, including some courts of appeals, have rejected challenges based on the 1st and 14th Amendments, but those cases mainly involved state laws.  Although the challengers in the Tampa case – Robert L. Vazzo, David Pickup, and Soli Deo Gloria International, Inc. – made those same constitutional arguments, which provided the basis for their case to be in federal court, Judge Jung resolved the case on a state law basis that appeared to be a mere make-weight in the original Complaint.

Tampa passed its ordinance in April 2017.  It bans “therapy” within the City by medical doctors and mental health professionals intended to assist minors to avoid being gay or transgender.  The ordinance uses the term “conversion therapy,” but the practice is also sometimes referred to as “sexual orientation change efforts” or SOCE.  The ordinance cites numerous professional studies discrediting SOCE and contending that it may be harmful to minors, and also cites decisions by the U.S. Courts of Appeals for the 3rd and 9th Circuits upholding New Jersey and California statutes making the performance of this “therapy” a violation of licensing standards that could subject the practitioners to penalties and possible loss of licensure.  A New Jersey state court has also condemned the practice under that state’s consumer fraud statute.

The Tampa City Council stated its intention to protect minors from being subjected to a potentially harmful practice, premised on its authority to exercise its police power for the public safety, health and welfare.  Enforcement was assigned to the same city employees who enforce other standards and codes.

Vazzo, a marriage and family therapist licensed in Florida, practices SOCE on minors, claiming that his treatment may help minors “reduce or eliminate same-sex sexual attractions, behaviors or identity,” and claiming that his therapy is rendered entirely in speech.  He also claimed that all clients initiate SOCE counseling by giving informed consent; a questionable assertion when they are minors who, under the law, are recognized as having only limited capacity to give legal consent to a variety of things.  As a practical matter, this normally involves parents who want to “cure” their children from being gay or trans and give consent to the SOCE practitioner on their children’s behalf.

Co-plaintiff David Pickup was the lead plaintiff in a case challenging California’s state law ban on SOCE, and claims in this case that he had intended to get Florida certification and treat patients in Tampa.  The other plaintiff is an organization that refers individuals, including minors, for SOCE treatment.

Jung invoked a doctrine called “implied preemption.”  When a state pervasively regulates a particular activity, it may be found to have “occupied the field” of regulating that activity, thus depriving local governments of doing the same, particularly if the local regulation may conflict in some way with the state regulation or interfere with the state’s ability effectively to regulate.  By contrast, the doctrine of “express preemption” applies to situations where the state constitution or a state law or regulation explicitly reserves sole authority over a particular subject to the state.  Thus, application of implied preemption requires the court to provide a justification for finding that the local government should not be allowed to regulate a particular activity, whereas “express preemption” relies on a clear statement by the legislature that its regulation of a field is exclusive.

Analyzing implied preemption in this case, Judge Jung wrote, “There is no grant of authority by the Florida legislature to municipalities to substantively regulate healthcare treatment and discipline.  The State, not localities, occupies this field. . .  Here, there is nothing local or unique to Tampa about SOCE that would suggest the statewide, uniform medical regulation regime should vary because of Tampa’s peculiarities, and should vary across the State, from town to town and from county to county. The matter legislated against – SOCE – is statewide, not Tampa-specific.  And, a uniform and statewide system of healthcare treatment and practitioner discipline already exists, for sound reasons.  Implied preemption is a disfavored remedy because cities have broad powers to address municipal concerns.  But substantive regulation of psychotherapy is a State, not a municipal concern.”

The judge also suggested that the Tampa Ordinance “encroaches upon” five state-mandated areas.

First, he found that Florida’s constitution protects a broad right of privacy against government intrusions, which “suggests that government should stay out of the therapy room.”

Second, he notes that Florida court cases recognize that “with very few exceptions, parents are responsible for selecting the manner of medical treatment received by their children,” and the ordinance interferes with the right of parents to select SOCE for their children.

Third, he points to the state’s statutory “Patient Bill of Rights,” which protects a patient’s right to select the course of treatment that he or she deems best.  He finds that “the Tampa Ordinance enters this area at odds with this portion of the Florida statutory scheme.”

Fourth, he notes a provision of the Florida law regulating health care which states, as “legislative intent,” that “citizens be able to make informed choices for any type of health care they deem to be an effective option for treating human disease, pain, injury, deformity, or other physical or mental condition,” and that “the health care practitioner may, in his or her discretion and without restriction, recommend any mode or treatment that is, in his or her judgment, in the best interest of the patience in accordance with the provisions of his or her license.”  He asserts that the Tampa Ordinance seeks to place a restriction where state law says there should be none.

Fifth, he asserts that the Tampa Ordinance interferes with the state’s statutory doctrine of informed consent.  Florida law allows health care workers to perform procedures with the informed consent of their patients, by protecting doctors against liability for performing procedures with a patient’s informed consent “so long as the substantial risks and hazards are fully disclosed and accepted.”  He finds that the Tampa Ordinance “simply ignores this well-known and broad Florida concept of informed consent,” subjecting health care practitioners to potential sanctions if they perform SOCE with the full informed consent of their patients.

In effect, he finds, if opponents of SOCE want to see the government restrict health care practitioners from engaging in this practice, they have to convince the medical boards that control the licensing practice that they should condemn SOCE as a violation of standards, or get the legislature to ban the practice.  “Tampa’s divergent standard for punishing errant mental health therapy is relevant in the preemption analysis because it creates a danger of conflict with an area pervasively regulated, for which the Legislature has stated a policy of statewide uniformity,” he concluded, noting particularly the detailed regulations and educational requirements for those seeking to hold the kind of licensing certification that Vazzo has earned.

Judge Jung, treading in controversial waters, goes on to challenge the competency of the Tampa City Council to set standards for medical practice.  “With due respect for the citizen legislators on the Tampa City Council, none are skilled in mental health issues,” he wrote, “nor are any of the City’s code enforcement personnel.  In contrast the Florida Department of Health, with its skilled adjudicatory bodies, is equipped to address this dynamic area of psychotherapy.”  Then he challenges the “certitude” of the City Council’s factual findings by cherry picking isolated statements from statements by the city’s expert witnesses in this case that might be used to impugn some of the conclusions about SOCE and its effects.  Asserting that “the field of gender expression is especially complex,” he suggests that it is best left to the state regulators.

Having decided the case entirely on preemption grounds, Judge Jung expressed no view regarding the constitutional arguments under the 1st and 14th Amendments.  Those arguments have been mainly rejected by the courts, although some uncertainty has been injecting into this field by comments made by Supreme Court Justice Clarence Thomas last year in an unrelated case, in which he castigated the concept of “professional speech” and cited with disdain the 3rd and 9th Circuit decisions mentioned above for having used that concept to analyze the 1st Amendment free speech issues.

Ironically, at the same time as Judge Jung was rendering his decision, rulings rejecting challenges to anti-conversion therapy laws passed by two other local Florida governments are on appeal before the 11th Circuit Court of Appeals.  The Florida legislature and state house, fully controlled by Republicans, are not going to address this issue, which is why Florida has been a hotbed of local legislative activity.  It will be interesting to see whether the preemption issue is raised by the 11th Circuit in considering the appeals in those cases, and whether the City of Tampa – which has an out lesbian mayor and a very political active LGBTQ community – will seek to appeal this ruling.

Vazzo and his co-plaintiffs are represented by lawyers from Liberty Counsel, an advocacy legal organization that seeks to deny liberty to LGBTQ people whenever possible.

Judge Jung, appointed by President Donald Trump, has been on the bench for barely a year.

 

 

Federal Court Narrows Discovery in Trans Military Case, but Rejects Government’s Broad Privilege Claims

Posted on: September 20th, 2019 by Art Leonard No Comments

U.S. District Judge Colleen Kollar-Kotelly, ruling in the first of four pending lawsuits challenging the current version of the military policy on transgender service, issued a wide-ranging ruling on September 13 attempting to settle some of the remaining problems in deciding what information the plaintiffs are entitled to obtain through discovery as the case continues. The case, renamed since President Trump was removed as a defendant and James Mattis quit as Defense Secretary, is now called Jane Doe 2 v. Mark T. Esper, 2019 WL 4394842, 2019 U.S. Dist. LEXIS 156803 (D.D.C., September 13, 2019)

The decision makes clear that the court has rejected the government’s argument that the so-called “Mattis Plan,” implemented in April 2019 after the Supreme Court voted to stay the preliminary injunctions that had been issued by the district courts, is entitled to virtually total deference from the court, thus precluding any discovery into how the Mattis Plan was put together, allegedly by a task force of experts convened by Defense Secretary James Mattis in response to the president’s request for a plan to implement the total ban on transgender service that he announced by tweet in July 2017.

When Trump came into office, transgender people were serving openly in the military as a result of a policy announced at the end of June 2016 by President Obama’s Defense Secretary, Ashton Carter.  The Carter policy lifted the existing ban on open transgender military service, but delayed lifting the ban on enlistment of transgender people for one year.  The first move by the Trump Administration concerning this policy was an announcement by Secretary Mattis at the end of June 2017 that he would not lift the enlistment ban until January 2018 in order to make sure that all necessary policies were in place to evaluate transgender applicants for enlistment.

A few weeks later, catching just about everybody by surprise, President Trump tweeted his announcement of a total ban on transgender people serving.  This was followedby a White House memorandum in August 2017, delaying enlistment of transgender people indefinitely, but allowing those already in the military to continue serving until March 2018 while Secretary Mattis came up with an implementation plan to recommend to the president.

Starting in August 2017 and continuing into the fall, four law suits were filed in federal district courts around the country challenging the constitutionality of the ban as announced by the President.  Federal district judges issued preliminary injunctions in all four lawsuits while denying the government’s motion to dismiss them, setting the stage for discovery to begin.  Discovery is the phase of a lawsuit during which the parties can request information, testimony and documents from each other in order to build a factual record for the decision of the case, and under federal discovery rules, anything that may be relevant to decide the case may be discoverable, subject to privileges that parties may assert.

In February 2018, Secretary Mattis released a report, purportedly compiled by a task force of senior military personnel and experts whom Mattis did not identify, discussing transgender military service and recommending a policy that differed in many respects from the absolute ban Trump had announced.  Under this proposed policy, the enlistment ban would be relaxed for transgender people who have not been diagnosed with gender dysphoria and are willing to serve in their gender as identified at birth.  The policy would allow transgender people who were serving to continue doing so.  Those who were transitioning as of the date the policy was implemented would be allowed to complete their transition and serve in their desired gender.  Otherwise, transgender personnel would have to serve in their gender as identified at birth, and would be separated from the service if they were diagnosed with gender dysphoria.  Nobody would be allowed to initiate transition while in the military once this policy was implemented.  There was no guarantee that transgender personnel would be allowed re-enlist at the end of their term of enlistment unless they met the same standards as a new applicant.  In short, the proposed policy would allow some transgender people to serve, but not all who were otherwise qualified, and would place certain restrictions on those who were allowed to continue serving.

Trump’s response to the recommendation was to revoke his prior policy announcements and to authorize Mattis to implement what became known as the Mattis Plan.  However, all the preliminary injunctions were still in place, so the government concentrated on getting the injunctions dissolved or withdrawn and getting the district judges to dismiss the cases on the ground that the policy they were attacking no longer existed.  The district judges resisted this move, some appeals were taken to the courts of appeals, and ultimately the Mattis Plan was implemented more than a year after it was proposed to the president, when the Supreme Court cut through the procedural difficulties and ruled, without a written opinion, that the Mattis Plan could go into effect while the lawsuits continued.

The focus of the lawsuits now switched to challenge the constitutionality of the Mattis Plan, and the parties went back to battling about discovery after it was clear that the district courts would not dismiss these lawsuits merely because one plan had been substituted for another.  Although some transgender people can serve under the Mattis Plan, the Plan still discriminates both against transgender people who have been diagnosed with gender dysphoria and against those who have not by requiring them to forego obtaining a diagnosis and transitioning if they want to serve.

One of the issues for Judge Kollar-Kotelly was deciding whether the government was correct to argue that because the Mattis Plan resulted from a Task Force study and recommendation process, it was entitled to standard military deference, under which courts disclaim the power to second-guess the personnel policies the military adopts.  The government focused particularly on a concurring opinion in the D.C. Circuit panel opinion that had quashed the preliminary injunction in this case, which arguably supported the view that plaintiffs were not entitled to discovery of documents and testimony related to the “deliberative process” by which the Mattis Plan was devised.

The judge responded that this was the central issue of the case: whether the Mattis Plan is entitled to standard military deference.  She found that the concurring judge, Stephen Williams, was alone in his view, as the other two members of the D.C. Circuit panel, faithful to Supreme Court precedents, had not opposed discovery, find that the deference question turned on whether the Mattis Plan is “the result of reasoned decision-making” that relates to military readiness concerns.  If, as the plaintiffs suspect and have argued all along, Trump’s motivation in banning transgender military service was motivated by politics, not by any evidence that the Ashton Carter policy had harmed the military by allowing unqualified people to serve, it would not be the result of “reasoned decision-making “and thus not entitled to deference.

Agreeing with the plaintiffs, Judge Kollar-Kotelly wrote that she could not decide the appropriate level of deference (or non-deference) without access to information about how the Mattis Plan was devised.  Thus discovery should continue ,focused on that.  However, she rejected the plaintiffs’ argument that they should be allowed to conduct discovery on Mattis’s initial decision to delay enlistments for six months, or on the process by which Trump formulated the July 2017 total ban announced in his tweet and elaborated in the White House’s August 2017 memorandum. Those, she found, are no longer relevant when the focus of the lawsuit has shifted to the constitutionality of the Mattis Plan.

As to that, however, the judge ruled that the government’s attempt to shield access to relevant information under the “deliberative process privilege” was not applicable to this case.  Just as the current state of the record is inadequate to determine the level of deference, discovery of the deliberative process by which the Mattis Plan was devised is necessary to determine whether it is the “result of reasoned decision-making.”

The judge reviewed a checklist of factors created by the D.C. Circuit Court of Appeals in earlier cases to determine whether the deliberative process privilege should be set aside in a particular case, and found that the plaintiffs’ requests checked all the necessary boxes.  The information is essential to decide the case, it is not available elsewhere than from the government, and the court can use various procedures to ensure that information that needs to be kept confidential can be protected from general exposure through limitations on who can see it, known as protective orders.  Furthermore, the parties can apply to the court for determination of whether any particular document need not be disclosed in discovery on grounds of relevance.

The government was particularly reluctant to comply with the plaintiffs’ request for “raw data and personnel files.”  The plaintiffs sought this in order to determine whether the factual claims made in the Task Force Report are based on documented facts, especially the claims in the Report that allowing persons who have been diagnosed with gender dysphoria to serve will be harmful to military readiness because of limitations on deployment during transitioning and geographical limitations on deployment due to ongoing medical issues after transition.  Critics have pointed out that the Report seems to be based more on the kind of propaganda emanating from anti-transgender groups than on a realistic appraisal of the experience in the military since Secretary Carter lifted the former ban effective July 1, 2016.  Since transgender people in various stages of transition have been serving openly for a few years, there are medical and performance records that could be examined to provide such information, but the government has been refusing to disclose it, claiming both that it raises privacy concerns and that disclosure is unnecessary because the Mattis Plan is entitled to deference as a military policy.

The judge found that it should be possible for these records to be discovered by redacting individually identifying information and imposing limitations on who can see the information and how it can be used.  Thus, the privacy concerns raised by the government should not be an impediment.  And this information, once again, is very relevant to the question whether the statements about the service qualifications of transgender people are based on biased opinions rather than facts, thus discrediting the claim that the policy is the result of reasoned decision-making.

The Trump Administration’s strategy in this, as in many other ongoing lawsuits concerning controversial policy decisions, has been to fight against discovery at every stage and to appeal every ruling adverse to them, including trying to “jump over” the courts of appeals to get the Supreme Court to intervene on the government’s behalf, now that Trump has succeeded in fortifying the conservative majority on the Court with the additions of Justices Gorsuch and Kavanaugh.  It would not be surprising if the government seeks to appeal Judge Kollar-Kotelly’s ruling to the D.C. Circuit once again to put off (perhaps permanently) the day when they will have to give up the identities of the Mattis Task Force members and open the books on how this policy – obviously political in its conception and implementation – was conceived.

Of course, if the White House changes hands in January 2021, a Democrat president could reverse the ban in any of its forms with a quick Executive Order restoring Secretary Carter’s policy from 2016.  As the four lawsuits continue to be bogged down in discovery disputes, that may be the way this story eventually ends.  If Trump is re-elected, the story continues to drag out while the Mattis Plan stays in place.

The plaintiffs are represented by a growing army of volunteer big firm attorneys and public interest lawyers from GLAD (GLBTQ Legal Advocates & Defenders) and the National Center for Lesbian Rights.

Federal Court Permanently Enjoins Wisconsin Medicaid from Enforcing State Statutory Exclusion of Coverage for Gender Transition

Posted on: August 26th, 2019 by Art Leonard No Comments

Last year, U.S. District Judge William M. Conley granted a preliminary injunction to several named plaintiffs in a case challenging a 1996 amendment to Wisconsin’s Medicaid statute under which transgender Medicaid participants were denied coverage for their gender transitions.  At that time, the court had concluded that the plaintiffs were likely to win their case on the merits and that delaying their access to gender transition coverage pending a final ruling on the merits would cause them irreparable injury, far outweighing any harm to the state.  The court refused to stay its preliminary injunction pending a possible appeal.  On August 16, Judge Conley issued his final ruling on the merits in the case, having in the interim certified it as a class action extending to all transgender people in the state who relied on Medicaid for their health care coverage, and making the injunction permanent.  The judge ordered the parties to “meet and confer” within 14 days on the scope of relief and final wording of an injunction.  Flack v. Wisconsin Department of Health Services, 2019 U.S. Dist. LEXIS 139388, 2019 WL 3858297 (W.D. Wis., Aug. 16, 2019).

Judge Conley premised his ruling on three sources of law: Section 1557 of the Affordable Care Act, the “Availability and Comparability” provisions of the Medicaid Act, and the Equal Protection Clause of the 14th Amendment.  Providing three independent and equal bases for the ruling makes it eminently defensible should the state decided to seek review at the 7th Circuit.  In this connection, the 7th Circuit has previously found thta government policies that disadvantage transgender people may violate the Equal Protection Clause, and it has adopted an interpretation of Title IX of the Education Amendments of 1972 that accepts the contention that a federal law banning sex discrimination would extend to gender identity discrimination, although this holding might be adversely affected by a Supreme Court ruling under Title VII in a pending case from the 6th Circuit, R.G. & G.R. Harris Funeral Homes v. EEOC, to be argued on October 8.

Judge Conley accepted the plaintiffs’ contention that the standards of care for gender dysphoria published by the World Professional Association of Transgender Health (WPATH), most recently updated in 2011, as supplemented by clinical guidelines on hormone treatment for gender dysphoria published in 2017 by the Endocrine Society, represent a medical consensus recognized by numerous professional health care associations and many, many court decisions, defining the standard of care in the context of any dispute about medically necessary treatment for gender dysphoria.  There is near-unanimity among federal courts at this point that gender dysphoria can be a serious medical condition and that, depending on the symptoms of the individual transgender person, various forms of treatment involved in transition, including hormone therapy and gender confirmation surgery (GCS), may be medically necessary.  The published standards emphasize, as does Judge Conley, that not every person who identifies as transgender experiences gender dysphoria (a “disconnect” between their gender identity and their anatomy), and that there is a range of severity, so not every person with gender dysphoria will necessarily seek GCS.  The Medicaid program’s coverage should depend upon competent medical professionals diagnosing gender dysphoria in the individual case and determining that hormone therapy and or GCS are medically necessary for the individual in question.

A significant problem for the defendants in this case, who include various officials as well as the state’s health services department, was that the legislature, evidently for political reasons, voted in 1996 to forbid the use of state Medicaid funds for gender transition, even though the particular treatments and procedures involved remain covered for a variety of other medical conditions.  For example, somebody suffering a severe hormone deficiency could obtain hormone replacement therapy under Medicaid, and a woman with breast cancer would be covered for a mastectomy, while transgender people would be denied coverage for hormone therapy or mastectomies, even though there was a medical consensus that these treatments were necessary to deal with their gender dysphoria.  The legislature did not undertake any serious study of the expenses of providing such treatment or of the professional medical standards in effect for treating gender dysphoria at that time.  The state tried to defend the statute in this case by coming up with various post hoc arguments that were easily discredited by the court, which observed that the state had failed to present credible expert testimony that there was a sound medical reason to deny the specified procedures to individuals for whom it was medically necessary.

The bulk of Judge Conley’s opinion is devoted to describing the medical evidence in the case, much of it derived from expert testimony provided by the plaintiffs, whose two expert witnesses were experienced medical specialists who had treated hundreds of transgender individuals and who were well-recognized in their field.  The state’s response to this, from the point of view of litigation strategy, was pathetic.  It failed even to offer experts with facially relevant expertise to contest any of the medical evidence.  Indeed, officials of the Wisconsin Medicaid program conceded in their testimony that the WPATH standards describe safe and effective treatments for gender dysphoria in appropriate cases, and there was little dispute that the named plaintiffs qualified for these treatments but were denied coverage for them solely because of the statute.  The court also pointed out that the state had attempted to rely in its arguments on materials that could not have provided a basis for the statute when it was passed, because their publication post-dated it.  In addition, Judge Conley observed that scientific knowledge about gender identity had significantly moved on since the mid-1990s, making the treatments and procedures even safer and more effective today.

The defendants sought to rely on two decision from other circuits: Kosilek v. Spencer, 774 F.3d 63 (1st Cir. en banc, 2014), and Gibson v. Collier, 920 F.3d 212 (5th Cir. 2019), but Judge Conley concluded these rulings were not persuasive precedents for this case.

Kosilek culminated long-running litigation and was based on expert testimony presented to the trial court in 2006, predating the current WPATH and Endocrine Society standards.  Also, the en banc 1st Circuit, which was ruling on the question whether GCS was medically necessary in the 8th Amendment context of a state prisoner serving a life sentence for murder (and which, incidentally, was reversing a 3-judge panel decision in the plaintiff’s favor), was heavily influenced by prison security concerns raised by the state that are not relevant in to Medicaid.

As to Gibson, Judge Conley performed a total demolition job on the cock-eyed reasoning of the 5th Circuit panel, whose opinion was written by Trump appointee James Ho.  This was also a prisoner case, the issue being whether it violated the 8th Amendment for the state to maintain a categorical refusal to provide GCS to transgender inmates (unlike in Kosilek, where the court focused on the individual inmate rather than an explicitly categorical treatment ban).  Gibson was a pro se case at the trial level, where the unrepresented inmate was incapable of compiling a state-of-the-art record of expert medical testimony, leaving a factual record bare of the kind of detailed information available to Judge Conley in this case litigated by experience attorneys.  In the absence of such a record, Judge Ho invoked the 1st Circuit’s decision in Kosilek, with its reliance on out-of-date information.  Of course, unlike the present Medicaid case, a case involving a prison setting raises different issues.  On the other hand, Judge Conley’s opinion leaves little doubt that he found the 5th Circuit’s analysis unpersuasive on the key points in common: whether there is a medical consensus that GCS can be medically necessary and that it is a safe and effective treatment.

For the short Affordable Care Act portion of his analysis, Judge Conley refers the reader to his earlier preliminary injunction decision.  As to the Medicaid portion, he details the requirement under Medicaid to cover medically necessary treatments, and furthermore the specific ban on discriminating in coverage decisions depending on the diagnosis of the individual participant.  In the Equal Protection portion of the opinion, he explained that the parties agree that Equal Protection claims by transgender plaintiffs are subject to “some sort of heightened scrutiny,” requiring the state to take on the burden of proving that it has an “exceedingly persuasive” justification for carving out this particular exception from its Medicaid coverage.  The government’s justification, stated now in its defense of the 1996 enactment, was “containing costs and protecting public health in face of uncertainty.”  Conley found neither justification to be sufficient under heightened scrutiny.  For one thing, the state conceded that the legislature made no study prior to passing the statute, either of the costs involved in providing coverage or of the medical facts surrounding gender transition and available treatments.  The only cost projections introduced by the state now were undertaken in response to this litigation, two decades later, and showed that the additional cost to the state’s Medicaid budget on an annual basis amounted to little more than a rounding error.  And, the court observed, there was no credible evidence to support the contention that covering these procedures would endanger public health.

The court also rejected a “spending clause” constitutional argument raised for the first time in support of the state’s opposition to plaintiffs’ summary judgment motion: that it was somehow unfair to the state to impose this “new” burden on it as a matter of federal law when it wasn’t contemplated at the time the state agreed to expand the Medicaid program in response to the Affordable Care Act in 2014.   “Nonsense,” wrote the judge.  Too late, and too bad.

Plaintiffs are represented by attorneys from McNally Peterson, S.C, Milwaukee; Dane & Colfax PLLC, Washington; Abigail Koelzer Coursolle of the National Health Law Program, Los Angeles; and Catherine Anne McKee of the National Health Law Program, Washington.

Masterpiece Baker Phillips Wins a Round in New Lawsuit Against Colorado Civil Rights Officials

Posted on: January 9th, 2019 by Art Leonard No Comments

Masterpiece Cakeshop baker Jack Phillips is back in court again, this time suing officials of Colorado’s Civil Rights agency and the state’s attorney general and governor to try to block the Commission from continuing a case against him for refusing to make a custom-designed cake to celebrate a transgender attorney’s celebration of the anniversary of her transition. On February 4, Senior U.S. District Judge Wiley Y. Daniel largely rejected a motion by defendants to dismiss the case, although he narrowed its scope somewhat.

For those coming in late to this ongoing drama: Phillips and Masterpiece Cakeshop were found by the Commission and the Colorado Court of Appeals to have violated the state’s public accommodations law when he refused to make a wedding cake for a gay couple in 2012 because of his religious objection to same-sex marriage. The U.S. Supreme Court reversed those decisions in a 7-2 ruling last June 4, based on the Court’s conclusion that the state had not afforded Phillips a “neutral” forum to consider his 1st Amendment defense.

Part of the Court’s conclusion that the Commission was “hostile” to Phillips on religious grounds rested on the Commission’s treatment of a provocateur named William Jack. While the discrimination claim by a gay couple was pending before the Commission, Jack approached three Colorado bakeries that custom-decorate cakes, asking them to make cakes for him that “conveyed disapproval of same-sex marriage, along with religious text,” quoting here from Justice Anthony M. Kennedy’s opinion for the Supreme Court. All the bakers turned him down, stating that they “objected to those cakes’ messages and would not create them for anyone.” Jack filed discrimination charges against the bakeries, but after investigating his charges, the Colorado Civil Rights Division found no “probable cause” that the statute was violated, and the Commission affirmed that determination.

The Supreme Court seized upon the Commission’s response to Jack’s provocation, saying that the Commission’s hostility was evident in “the difference in treatment between Phillips’ case and the cases of other bakers who objected to a requested cake on the basis of conscience and prevailed before the Commission.” The Civil Rights Division ruled in Phillips’ case that “any message the requested wedding cake would carry would be attributed to the customer, not the baker,” while “the Division did not address this point in any of the other cases with respect to the cakes depicting anti-gay marriage symbolism.” Justice Kennedy also critically noted that “the Division found no violation of the Act in the other cases in part because each bakery was willing to sell other products to the prospective customers” but the “Commission dismissed Phillips’ willingness to sell birthday cakes, shower cakes, cookies and brownies, to gay and lesbian customers as irrelevant.”

The Supreme Court had announced its decision to grant Jack Phillips’ petition for review on June 26, 2017 – an announcement that received widespread media coverage and apparently prompted Autumn Scardia, a transgender attorney, to take a leaf from William Jack’s book. She phoned Masterpiece and inquired about getting a cake with a blue exterior and a pink interior to “celebrate her transition from male to female.” Scardina said she wanted the cake for a birthday party she was planning. It was only when she described the color scheme and the reason for it that Phillips turned down the order, stating that he would not make a cake celebrating a gender transition for “any customer, no matter the customer’s protected characteristics.” In his current lawsuit, he alleges that he “offered to create a different custom cake for Scardina or to sell her any of the pre-make items available for purchase.” But she declined to order anything else.

Scardina filed a discrimination charge with the Division. Several weeks after the Supreme Court ruled on the first Masterpiece Cakeshop case, the Division issued a probable cause determination against Phillips for violating the public accommodations law by refusing Scardina’s cake order. While noting the religious reasons cited by Phillips for specifically not making a cake designed to celebrate a gender transition, due to his religious belief that a person’s sex is “an immutable God-given reality,” the Commission nonetheless concluded that “the refusal to provide service to Complainant was based on her transgender status.”

On October 2, 2018, the Commission filed a formal complaint against Phillips based on the Division’s finding, and set the case for a hearing. Anticipating this move, Phillips filed a complaint in federal court on August 14, 2018, which the defendants promptly moved to dismiss. Phillips charges that the state is out to get him, characterizing its actions as “unconstitutional bullying.” After the defendants’ dismissal motion and the Commission’s formal complaint were filed, Phillips filed an amended complaint to take account of these developments. The Commission’s hearing. The hearing has not yet taken place.

Phillips claims that the defendants’ interpretation of the public accommodations law violates his First Amendment rights to free exercise of religion and freedom of speech. He also makes a Due Process vagueness claim against the statute, attacking it on several grounds, including a structural charge against the statutory criteria for the appointment of Commission members by the governor, which require, among other things, that several members of the Commission be representative of minority communities protected by the anti-discrimination law. He also asserted an equal protection claim, focused again on the differential treatment cited by the Supreme Court in noting the Commission’s refusal to prosecute the bakers who had turned down William Jack’s order for “anti-same-sex marriage cakes.”

Phillips sought injunctions against the state officials forbidding them from interpreting and enforcing the statute against him. He also sought a judicial declaration about the violation of his constitutional rights, and compensatory, punitive and nominal damages against the Civil Rights Division’s Director, Aubrey Elenis, and the seven members of the Commission.

In ruling on the motion to dismiss, Judge Daniel found that none of the “abstention doctrines” that the federal courts have developed to determine whether to allow federal lawsuits to interfere with state administrative proceedings should apply in this case, and that Phillips had standing to bring this lawsuit, not only because of the proceedings ongoing against him, but also because he wanted to post a policy statement on his business’s website about the basis on which they would refuse to make custom-cakes, but was inhibited from doing so because a section of the public accommodations law states that businesses cannot publish discriminatory policies.

However, Daniel did find that Director Elenis and the individual Civil Rights Commissioners enjoy absolute immunity from personal liability for damages, accepting their argument that they are acting as prosecutors and adjudicators. He wrote that it is “well-established that prosecutors are absolutely immune for activities which are intimately associated with the judicial process such as initiating and pursuing” a prosecution. He found that the U.S. Court of Appeals for the 10th Circuit, whose rulings are binding on the district court in Colorado, has “extended absolute immunity to state administrative or executive officials serving in adjudicative, judicial, or prosecutorial capacities.”

Furthermore, the judge found that Governor John Hickenlooper should be dismissed as a defendant, since he played no direct role in enforcing the public accommodations law, so suit against him in his official capacity was barred by the 11th Amendment. Just in time, it seems, since Hickenlooper’s term ended a few days after the court issued it January 4 decision, with Governor Jared Polis taking office on January 8. This decision means that Polis, the state’s (and nation’s) first out gay man to be elected a governor, did not become a defendant in this lawsuit immediately on taking office!

However, the court refused to dismiss the Attorney General, Cynthia Coffman, from the case, finding that the attorney general’s role of representing the Commission in court did make that office potentially subject to injunctive relief. Once again, however, the timing was fortuitous, since Coffman’s term has also ended, as Phil Weiser took office as attorney general on January 8, and the defense of this case will be carried on by his office.

Of course, Phillips is represented by Alliance Defending Freedom, the right-wing Christian litigation group that represented him in appealing the wedding cake decision to the Supreme Court. Not coincidentally, ADF also represents Harris Funeral Homes, seeking Supreme Court review of the 6th Circuit’s decision that Harris violated Title VII of the Civil Rights Act when it fired a transgender funeral director, as well as anonymous plaintiffs who are asking the Supreme Court to overturn the 3rd Circuit’s decision rejecting a constitutional challenge to the Boyertown, Pennsylvania, school district’s transgender-affirmative facilities access policy. One of the best ways to keep up with some major cases in LGBT-related litigation is to periodically visit ADF’s website.