Full opinion text
MEMORANDUM OPINION AND ORDER REGARDING DEFENDANT’S MOTION TO DISMISS FOR LACK OF SUBJECT MATTER JURISDICTION AND TRIAL ON THE MERITS BENNETT, District Judge. TABLE OF CONTENTS I. INTRODUCTION. 740 A. Initial Findings Of Fact. 740 1. Gender identity disorder. 740 2. Smith’s condition. 743 B. Procedural Background. 744 II. LEGAL ANALYSIS. 746 A. Subject Matter Jurisdiction . 746 1. Arguments of the parties. 746 2. Justiciability. 747 a. Standing. 749 i. Constitutional and prudential requirements 749 ii. Smith’s standing. 760 b. Ripeness. 751 i. Constitutional and prudential requirements 751 ii. Ripeness of Smith’s claim. 752 3. Disposition of the motion to dismiss. 752 B. The Merits. 753 1. The legal basis for Smith s claims. 753 a. The Director’s arguments. 753 b. Analysis.'_ 753 2. Iowa’s denial of coverage for sex reassignment surgery. 756 a. The Pinneke decision. 756 b. Reasonableness of the rule promulgation process. 757 c. Reasonableness of the rule. 760 i. Medicaid coverage for “experimental” treatments. 761 ii. Defendant’s evidence that sex reassignment surgery is experimental. 763 iii. Other evidence. 769 3. Is sex reassignment surgery “medically necessary” for Smith? 771 4. Is Smith “ready” for the final stage of sex reassignment surgery? 771 III. CONCLUSION. . 772 Resolution of this lawsuit is not as simple as deciding whether the plaintiff should be left “betwixt and between” genders as he seeks completion of female-to-male sex reassignment surgery at the expense of the Iowa Medicaid program. Probably nobody familiar with the record in this case would disagree with the observation of plaintiffs treating psychiatrist that being “left in the middle” would be “just a nightmare for anyone.” However, the ultimate question before the court is not whether the plaintiffs sex reassignment should be completed, but whether Medicaid should have to pay for it. Before even reaching the merits of that multifaceted question, the court must also determine whether this litigation, like the plaintiff, is caught “betwixt and between,” this time somewhere between plaintiffs concerns and a justiciable Article III “case or controversy” I. INTRODUCTION Plaintiff “John Smith” filed this action on May 19, 1997, seeking reimbursement under the Iowa Medicaid program for medically necessary surgical procedures, specifically, female-to-male sex reassignment surgery, as treatment for his gender identity disorder. He originally asserted that denial of Medicaid payments for his sex reassignment surgery was in violation of both Medicaid statutes and regulations and the due process clause of the Fourteenth Amendment to the United States Constitution. He has since withdrawn his due process claim, and at trial asserted only his claim that denial of payments for his sex reassignment surgery was in violation of the Medicaid statutes and regulations. Defendant Jessie K. Rasmussen, in her official capacity as the Director of the Iowa Department of Human Services (the Director), resists Smith’s claim for payment for the final stages of his sex reassignment surgery. A. Initial Findings Of Fact What follows is not an exhaustive recitation of the court’s findings of fact, but a statement of sufficient of the court’s findings and the parties’ factual contentions to provide a context for the legal analysis to follow. Because many of the issues that must be resolved in this case involve a complex intertwining of facts and law, pertinent findings of fact are interlaced with identification and application of the proper legal standards for resolution of those issues. 1. Gender identity disorder Plaintiff John Smith suffers from “gender dysphoria” or “gender identity disorder,” sometimes known as “transsexualism.” “Transsexualism” was in fact a diagnostic category under the criteria found in the third edition of the Diagnostic and Statistical Manual of Mental DisoRders, the so-called DSM-III-R, but the pertinent diagnosis is now “gender identity disorder.” See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). The DSM-IV identifies the general diagnostic features of this gender identity disorder as follows: There are two components of Gender Identity Disorder, both of which must be present to make the diagnosis. There must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is, of the other sex (Criterion A). This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. There must also be evidence of persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex (Criterion B). The diagnosis is not made if the individual has a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) (Criterion C). To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion D). DSM-IV, 532-33. Gender identity disorder is suffered by people of all ages, although it manifests differently at different ages: Distress or disability in individuals with Gender Identity Disorder is manifested differently across the life cycle. In young children, distress is manifested by the stated unhappiness about their assigned sex. Preoccupation with cross-gender wishes often interferes with ordinary activities. In older children, failure to develop age-appropriate same-sex peer relationships and skills often leads to isolation and distress, and some children may refuse to attend school because of teasing or pressure to dress in attire stereotypical of their assigned sex. In adolescents and adults, preoccupation with cross-gender wishes often interferes with ordinary activities. Relationship difficulties are common and functioning at school or at work may be impaired. Id. at 534. More particularly, because the plaintiff here is an adult with gender identity disorder, it is pertinent to note the DSM-IV’s description of adults with gender identity disorder: Adults with Gender Identity Disorder are preoccupied with their wish to live as a member of the other sex. This preoccupation may be manifested as an intense desire to adopt the social role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Adults with this disorder are uncomfortable being regarded by others as, or functioning in society as, a member of their designated sex. To varying degrees, they adopt the behavior, dress, and mannerisms of the other sex. In private, these individuals may spend much time cross-dressed and working on the appearance of being the other sex. Many attempt to pass in public as the other sex. With cross-dressing and hormonal treatments (and for males, electrolysis), many individuals with this disorder may pass convincingly as the other sex. The sexual activity of these individuals with same-sex partners is generally constrained by the preference that their partners neither see nor touch their genitals. For some males who present later in life, (often following marriage), sexual activity with a woman is accompanied by the fantasy of being lesbian lovers or that his partner is a man and he is a woman. Id. at 533-34. The Harry Benjamin International Gender Dysphoria Association, Inc., often called the “Harry Benjamin Society,” is a professional organization for persons involved in the diagnosis and treatment of gender identity disorder and related conditions. It is named after the first person to describe the syndrome, and the results of recent research into the nature or treatment of the condition are often first presented at its meetings. The Harry Benjamin Society has drafted the recognized standards of care for the hormonal and surgical sex reassignment of gender dys-phoric persons. See HarRY njamin InterNATIONAL Gender Dysphoria Association, Inc, Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons (Rev.1990) (hereinafter “Harry Benjamin Standards”). In these standards, hormonal sex reassignment is defined as follows: Hormonal sex reassignment refers to the administration of androgens to geno-typic and phenotypic females, and the administration of estrogens and/or pro-gesterones to genotypic and phenotypic males, for the purpose of effecting somatic changes in order for the patient to more closely approximate the physical appearance of the genotypically other sex. Hormonal sex-reassignment does not refer to the administration of hormones for the purpose of medical care and/or research conducted for the treatment or study of non-gender dysphoric medical conditions (e.g., aplastic anemia, impotence, cancer, etc.). Harry Benjamin Standards, 3.2. The Harry Benjamin Standards also define surgical sex reassignment as follows: Genital surgical sex reassignment refers to surgery of the genitalia and/or breasts performed for the purpose of altering the morphology in order to approximate the physical appearance of the genetically-other sex in persons diagnosed as gender dysphoric. Such surgical procedures as mastectomy, reduction mammoplasty, augmentation mammoplasty, castration, orchidectomy, penectomy, vaginoplasty, hysterectomy, salpingectomy, vaginectomy, oophorec-tomy and phalloplasty — in the absence of any diagnosable birth defect or other medically defined pathology, except gender dysphoria, are included in this category labeled surgical sex reassignment. Non-genital surgical sex reassignment refers to any and all other surgical procedures of non-genital, or non-breast sites (nose, throat, chin, cheeks, hips, etc.) conducted for the purpose of effecting a more masculine appearance in a genetic female or for the purpose of effecting a more feminine appearance in a genetic male, in the absence of identifiable pathology which would warrant such surgery regardless of the patient’s genetic sex (facial injuries, hermaphrodi-tism, etc.). Id. at 3.3. The DSM-IV indicates further that, based on data from smaller countries in Europe with access to total population statistics and referrals, “roughly 1 per 30,-000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery” for gender identity disorder. Id. at 585. Undocumented estimates are that between 30,000 and 60,000 United States citizens consider themselves to be valid candidates for sex reassignment, and that 3,000 to 6,000 Americans had been hormonally and surgically sex-reassigned as of 1979. HarRy Benjamin Standards, at 1. The Harry Benjamin Standards also state qualifications for persons who can recommend sex reassignment surgery and hormone therapy, and principles for determining when sex reassignment surgery should be recommended. Harry Benjamin Standards, passim. 2. Smith’s condition Smith was born female, but is now medically and legally classified as male. Smith grew up with adoptive parents from the time he was approximately two months old. He is now thirty-nine years old. He claims to be of at least one-eighth Native American extraction, which is something he says he always suspected, but was only able to confirm after his petition to open his adoption records was granted during his adulthood and he was able to talk to his birth mother. He is now an adherent of the Oglala religion or spirituality, which is practiced, for example, by the Lakota Sioux of the Pine Ridge, Rosebud, and Cheyenne River Reservations in North and South Dakota. To all outward appearances, Smith is male, and has, for example, found it difficult or impossible to use the women’s restroom in public places, and indeed he has consistently chosen to use the men’s room. He has always believed himself to be male, even to the point of refusing to wear dresses from as young as four years old, the age at which he testified that he was old enough to “fight them off’ when his parents attempted to put “girls’ ” clothes on him. Since his early youth, Smith has consistently adopted “male” attire. Smith can only remember willingly wearing female clothing on very few occasions: At his parents’ request, he wore a dress for high school graduation and, also at his parents’ request, he wore a dress for his older sister’s wedding. However, Smith discontinued participation in high school choir when school officials demanded that he wear dresses for performances. Smith habitually played “boys’ ” games and was interested and involved in typically male activities. As a consequence of his perception that he was male, puberty was a “tumultuous” time for Smith, as his body— despite his fervent hopes — developed female secondary sex characteristics. Smith has suffered from depression since early in his youth, and he has a longstanding diagnosis of suffering from depression. In addition, he was involved in a car accident in 1978 that injured his larynx and permanently affected his speech, despite corrective and reconstructive surgery. Smith also has a brain stem or closed-head injury from that accident, which has affected his memory and has been a cause of some of his behavior, such as hallucinations and hearing voices, that has from time to time been labeled as a psychiatric or psychotic phenomenon. Many of these supposedly psychotic phenomena, however, are in fact consistent with visions, which are part of his Oglala spirituality; other supposedly psychotic episodes are attributable to negative reactions to medications prescribed in attempts to treat his psychiatric conditions. However, there is no record of recent “psychotic” episodes, either religious visions, medication-related hallucinations, or symptoms of a mental condition. As a result of the settlement of a lawsuit arising from the car accident in 1978, Smith receives just over $500 per month from an annuity out of which he pays his living expenses. Smith is unable to work as the result of disabilities from his car accident and receives Iowa Medicaid assistance as a “medically needy” individual. Despite his disabilities, Smith obtained a B.A. degree in clinical psychology in 1982 and a M.A. degree in the same discipline in 1998. Smith had a hysterectomy with removal of one ovary in late 1992, which he concedes was only partly in furtherance of his sex reassignment. Other reasons for that surgery included his suffering from endometriosis, fibrocystic breast disease, and dysmenorrhea. Iowa Title XIX Medicaid benefits paid for Smith’s 1992 surgery. Medicaid also paid for a second surgery to remove Smith’s second ovary somewhat later, after he developed the same abdominal pain that had prompted the first surgery. On February 20, 1997, Smith had bilateral breast reduction and male chest contouring, which he considered to be part of his sex reassignment surgery, although medical conditions also provided some justification for the breast reduction. Smith sought payment for the 1997 surgery from Medicaid, but Medicaid denied the claim on the ground that the procedure constituted sex reassignment surgery not covered by Medicaid benefits. Smith therefore paid for this portion of his sex reassignment surgery himself. He is very satisfied with the results of all of these surgeries to date from the standpoint of sex reassignment. The remaining surgical portion of Smith’s sex reassignment would be a phalloplasty, or surgical construction of a new penis. It is who will pay for this final stage of his sex reassignment surgery that is at issue in this lawsuit. Prior to seeking Medicaid payment for the final stage of his sex reassignment surgery, Smith underwent psychotherapy, for both gender identity issues and other conditions, such as diagnoses for atypical bipolar disorder and depression. He has also attempted pharmacological treatment of his psychiatric conditions, with at best mixed results. As another part of his preparation for sex reassignment, Smith began receiving male hormone treatment, including intramuscular injection of testosterone, in January of 1997. Smith has also completed a “real life test,” which required him to live in his desired gender role for a significant period of time. Smith has in fact lived as a male for many years and has passed as a male in public at all times for many years. Smith explains his desire to complete surgical sex reassignment — in addition to simply living as a male — as based on his belief that his gender identity or sexual identity is a major component of who he is as a person, how he feels, thinks, behaves, and reacts. In short, Smith’s gender is “fundamental” to his identity. Completion of a phalloplasty, Smith states, and the court finds, will allow him to lead something approaching a more “normal life,” fulfilling his “need to be whole.” Practical problems he encounters lacking such surgery are in dating, using public restrooms, and otherwise passing for male in private or enclosed areas. Assuming it is appropriate to turn to the merits, over the assertion of a lack of subject matter jurisdiction by the Director of the IDHS, among the key questions the court will consider in more detail in the course of its legal analysis — and questions highlighting the interwoven nature of the factual and legal issues in this case — are whether sex reassignment surgery is an appropriate and “medically necessary” treatment for Smith’s gender identity disorder, and whether Smith is indeed “ready” for such final and irreversible treatment. B. Procedural Background ■■ As mentioned above, Smith filed the present lawsuit on May 19, 1997, and was granted leave to prosecute the action in forma pauperis and under a pseudonym. Also as explained above, the original corn-plaint asserted two claims: In Count I, Smith alleged that the denial of sex reassignment surgery violates the federal Medicaid statute and its attendant regulations; in Count II, Smith alleged that the denial of sex reassignment surgery violates his right to due process under the Fourteenth Amendment to the United States Constitution. The defendant Director of the IDHS answered the complaint on June 18, 1997, and subsequently moved for summary judgment almost a year later on June 1, 1998. This court denied the Director’s motion for summary judgment, concluding as follows: Initially, because the court concludes that 42 U.S.C. § 1396a(a)(17) creates a federal right, which is further defined in 42 C.F.R. § 440.230(b), that is sufficiently definite to be enforced under § 1983 and because Congress did not intend to foreclose private enforcement of the Medicaid statute, plaintiff Smith states a cause of action under § 1983 for violation of § 1396a(a)(17). The court also concludes that plaintiff Smith has generated a material question of fact as to whether sex reassignment surgery is a medically necessary treatment for plaintiff Smith’s gender dysphoria. Finally, the court concludes that plaintiff Smith has generated a genuine issue of material fact as to whether the Iowa Department of Human Services’ reliance on the Iowa Foundation For Medical Care’s report [to exclude Medicaid coverage for sex reassignment surgery] was a reasonable exercise of discretion. Therefore, defendant Palmer’s Motion For Summary Judgment is denied. Smith v. Palmer, 24 F.Supp.2d 955, 968 (N.D.Iowa 1998). In a trial brief, the Director of the IDHS asks the court to revisit these conclusions in the course of making a determination on the merits of Smith’s claim. On December 14, 1998, just before trial, Smith was granted leave to file an amended complaint. His amended complaint identified more specifically 42 U.S.C. § 1396a(a)(17) as the statutory basis for his claim in Count I and deleted entirely the due process claim in Count II. This court held a bench trial on Smith’s remaining claim beginning on December 16, 1998, and concluding on December 18, 1998. During the course of trial, questions were raised about the court’s subject matter jurisdiction. The Director of the IDHS formalized those concerns with a motion to dismiss on December 30, 1998, challenging the justiciability of Smith’s claim on the ground that Smith has failed to show that he is presently eligible for sex reassignment surgery or that sex reassignment surgery has been recommended by his treating physicians. Thus, the Director of the IDHS contends that there is no “ripe” Article III case or controversy. Post-trial briefing ensued on the question of the “ripeness” of Smith’s claim. After resisting the motion to dismiss by the Director of the IDHS on January 15, 1999, Smith attempted to file two supplemental memoranda in support of his resistance on January 21,1999, and January 25, 1999, respectively. The first supplemental memorandum included a letter dated January 14, 1999, from Smith’s treating psychiatrist and trial expert, Dr. Satterfield, including her recommendation that Smith is now ready for sex reassignment surgery. The second supplemental memorandum included a letter from Dr. Robiner, one of Smith’s treating psychologists who was not a witness at trial, also certifying that Smith is now ready for sex reassignment surgery. The court granted Smith’s motion to file the first supplemental memorandum, to which the Director of the IDHS subsequently objected. The Director also objected to the filing of the second supplemental memorandum, and sought leave, if the second supplemental memorandum was accepted by the court, to conduct additional discovery and to have an opportunity to name an additional expert to respond to Dr. Robiner’s testimony. By order dated February 8, 1999, this court denied Smith’s second motion to file a supplemental memorandum, denied the Director’s motion for additional discovery and to designate a new expert as moot, and granted the Director’s motion to reconsider the order granting Smith leave to file his first supplemental memorandum on certain conditions. Specifically, the court established a schedule for supplemental depositions, first, of Smith’s expert, Dr. Satterfield, concerning her new opinions as reflected in her letter accompanying the first supplemental memorandum, and, second, of the Director’s trial expert, Dr. Ka-valier, in order to allow him to respond to Dr. Satterfield’s new opinions. After an extension of time to take the supplemental deposition of Dr. Kavalier, the depositions of both experts were submitted as supplements to the trial record in April of 1999. The court heard oral arguments on the Director’s motion to dismiss and final arguments on trial on the merits on June 23, 1999. Plaintiff John Smith was represented by Thomas A.. Krause of Max Schott and Associates, P.C., in Des Moines, Iowa. Defendant Jessie K. Rasmussen, in her official capacity as Director of the Iowa Department of Human Services, was represented by counsel Daniel W. Hart, Assistant Iowa Attorney General, and Gordon E. Allen, Deputy Iowa Attorney General, in Des Moines, Iowa. Although the issues have been joined zealously, and the case is clearly hard fought, the court has been impressed with the courtesy with which all counsel have conducted the trial and arguments before the court. The court has also been impressed by the quality and thoroughness of the briefing of the various complicated issues this case has presented. The court finds that both the Director’s motion to dismiss for lack of subject matter jurisdiction and trial on the merits are now fully submitted and ripe for resolution. II. LEGAL ANALYSIS (Including some further findings of fact) The court will begin its legal analysis with the question last raised by the Director: Does the court have subject matter jurisdiction to entertain Smith’s claim at all? If subject matter jurisdiction is lacking, the court would have no authority to pass on the merits of Smith’s claim, except to the extent that the question of the “ripeness” of Smith’s claim is necessarily intertwined with the merits, that is, to the extent both questions in part depend upon whether Smith is “ready” for sex reassignment surgery. Nonetheless, a conclusion that Smith is “ready” for sex reassignment surgery, and therefore has presented a ripe “case or controversy,” does not necessarily answer the question of whether the treatment for which he is “ready” is also “medically necessary” within the meaning of the Medicaid statute. A. Subject Matter Jurisdiction 1. Arguments of the parties In a post-trial motion to dismiss for lack of subject matter jurisdiction, the Director asserts that Smith lacks standing to assert his claim and that even if he has standing, his claim is not “ripe.” The Director asserts that Smith is impermissibly requesting an advisory opinion that, if and when his own medical professional is willing to state that his desired surgery is medically necessary, Medicaid will be obligated to provide funding, but those future events are uncertain, contingent, may not occur as anticipated, or may never occur. In short, the Director asserts Smith’s claim is entirely hypothetical. Furthermore, the Director asserts that Smith will suffer no hardship from denial of a judicial decision on his claim until and unless he receives a medical opinion that he is ready for sex reassignment surgery. The Director objects to any delay in dismissal of Smith’s claim that might allow jurisdiction to attach. In a resistance to the motion to dismiss filed prior to the date of Dr. Satterfield’s letter certifying that Smith is now “ready” for completion of sex reassignment surgery, Smith argued that his need for sex reassignment was sufficiently real and immediate at the time of trial to satisfy the requirements of standing and -ripeness. He argued that his claim for a phalloplasty satisfied both constitutional and prudential requirements, because he has steadfastly pursued such surgery and has presented his claim in truly adversarial proceedings challenging a firmly established policy of the IDHS to deny Medicaid benefits for sex reassignment surgery. He also pointed out that sex reassignment is a multistage process and that he has completed all but the last stage, so that he is “in the middle” of the procedure, while asserting a claim for Medicaid coverage of the final stage. He argued that failure of the court to address his claim now would impose a severe hardship as completion of more legal proceedings to obtain the procedure would likely take several years, rather than the months before he would most certainly be ready for the surgery. He also argued that no further factual development of the record was required. In his supplemental brief, Smith presented the letter of Dr. Satterfield as establishing that he is now indeed “ready” for final sex reassignment surgery. He argues on the basis of this additional evidence that any questions about the immediacy of his claim have disappeared. As an alternative to this principal dispute over the ripeness of Smith’s claim for Medicaid coverage of his phalloplasty, Smith also asserted that his claim for reimbursement for breast reduction surgery was clearly ripe, because Medicaid had already denied coverage for that claim. In a reply brief, the Director argued that no such claim for reimbursement for the breast reduction surgery had ever been asserted either prior to or during trial. As the court pointed out at the end of trial, when the parties first addressed the question of subject matter jurisdiction, the only claim asserted in a timely fashion in this litigation is a claim for Medicaid payment for Smith’s phalloplasty. Therefore, neither jurisdiction nor relief will depend upon a claim for reimbursement for breast reduction surgery, as such a claim is not properly before the court. 2. Justiciability The federal district courts have always been courts of limited jurisdiction. See U.S. Const., Art. Ill, § 1. “Federal courts are not courts of general jurisdiction and have only the power that is authorized by Article III of the Constitution and the statutes enacted by Congress pursuant thereto.” Marine Equip. Management Co. v. United States, 4 F.3d 643, 646 (8th Cir.1993) (citing Bender v. Williamsport Area Sch. Dist., 475 U.S. 534, 541, 106 S.Ct. 1326, 89 L.Ed.2d 501 (1986), citing in turn Marbury v. Madison, 1 Cranch 137, 5 U.S. 137, 2 L.Ed. 60 (1803)); see also Mausolf v. Babbitt, 85 F.3d 1295, 1300 (8th Cir.1996) (Article III limits the “judicial power” to “cases” and “controversies,” citing U.S. Const., Art. III, § 2, cl. 1), Neighborhood Transp. Network, Inc. v. Pena, 42 F.3d 1169, 1171 (8th Cir.1994) (federal court jurisdiction is limited by Article III of the Constitution). “The existence of a live case or controversy is a constitutional prerequisite to the jurisdiction of the federal courts.” In re Grand Jury Subpoenas Duces Tecum, 78 F.3d 1307, 1310 (8th Cir.), cert. denied sub nom. Branscum v. United States, 519 U.S. 980, 117 S.Ct. 432, 136 L.Ed.2d 331 (1996), and cert. denied sub nom. Hill v. United States, 519 U.S. 981, 117 S.Ct. 432, 136 L.Ed.2d 331 (1996); see also Von Eye v. United States, 92 F.3d 681, 684 (8th Cir.1996) (quoting In re Grand Jury Subpoenas). “From this bedrock requirement [of a case or controversy] flow several doctrines — e.g., standing, mootness, ripeness, and political question — which state fundamental limits on federal judicial power in our system of government.” Mausolf, 85 F.3d at 1300 (internal quotation marks and citations omitted). Two of the doctrines going to the “justiciability” of Smith’s claim are at issue here, “ripeness” and “standing.” Although the doctrines of “ripeness” and “standing” are “technically different,” “they are closely related in that each focuses on ‘whether the harm asserted has matured sufficiently to warrant judicial intervention.’” Johnson v. Missouri, 142 F.3d 1087, 1090 n. 4 (8th Cir.1998) (quoting Warth v. Seldin, 422 U.S. 490, 499 n. 10, 95 S.Ct. 2197, 45 L.Ed.2d 343 (1975)). Both doctrines have constitutional and prudential dimensions. See Bennett v. Spear, 520 U.S. 154, 162, 117 S.Ct. 1154, 137 L.Ed.2d 281 (1997) (“The question of standing ‘involves both constitutional limitations on federal-court jurisdiction and prudential limitations on its exercise.’ ”) (quoting Warth v. Seldin, 422 U.S. 490, 498, 95 S.Ct. 2197, 45 L.Ed.2d 343 (1975)); McKenzie v. City of White Hall, 112 F.3d 313, 316 (8th Cir.1997) (to show that claims are “ripe,” the claimant must show both a constitutionally adequate “case or controversy” and that prudential considerations justify the exercise of judicial power). This court has explained that a federal court is charged with examining its jurisdiction at every step of the litigation. See Morris v. Winnebago Indus., Inc., 936 F.Supp. 1509, 1530 (N.D.Iowa 1996) (federal courts are courts of limited jurisdiction and must assure themselves that they have subject matter jurisdiction over claims before them at all stages of the proceedings, even if the parties do not raise the question of subject matter jurisdiction themselves, citing McCorkindale v. American Home Assur. Co., 909 F.Supp. 646, 649 n. 4 (N.D.Iowa 1995), and Laird v. Ramirez, 884 F.Supp. 1265, 1269-70 (N.D.Iowa 1995)). The Director specifically asserts that subject matter jurisdiction was missing at a critical step in this litigation, because this matter was neither ripe nor did Smith have standing to assert it at the time of trial, because Smith had not been certified as “ready” for the final stages of his sex reassignment surgery. The Director contends that Dr. Satterfield’s subsequent certification that Smith is now “ready” for completion of his sex reassignment surgery cannot rectify the lack of subject matter jurisdiction at the time of trial. Smith counters that Anderson v. Green, 513 U.S. 557, 115 S.Ct. 1059, 130 L.Ed.2d 1050 (1995), stands for the proposition that standing and ripeness requirements are considered in the situation at the time a decision is rendered. The court cannot read Anderson as broadly as Smith does. In Anderson, the Court was asked to consider a challenge by new residents of California to a statute of that state limiting for one year the AFDC benefits of such new residents to the level of benefits in the state from which they came. See Anderson, 513 U.S. at 558-59, 115 S.Ct. 1059. The Court found that California could only provide AFDC benefits with such a differential between new and long-time residents if it had in place a waiver from the Secretary of Health and Human Services (HHS). Id. at 559, 115 S.Ct. 1059. Although HHS had originally granted California such a waiver, the court of appeals below had vacated the HHS waiver in a separate proceeding prior to the case wending its way before the Court on certiorari. Id. In these circumstances, the Court found that at the time the matter was before it for decision, California could not treat the new residents any differently than it was treating long-time residents, and consequently no “ripe” controversy was then before the Court. Id. It is in this context that the Court used the language upon which Smith relies-language that, taken literally, might support his argument-that “ ‘ripe- ness is peculiarly a question of timing,” and ‘it is the situation now rather than the situation at the time of the [decision under review] that must govern.’ ” Id. (quoting Regional Rail Reorganization Act Cases, 419 U.S. 102, 140, 95 S.Ct. 335, 42 L.Ed.2d 320 (1974)). The quoted language, read in context, stands for no more than the unre- markable proposition that a case must re- main justiciable at the time a decision is time a decision is rendered; it does not stand for the proposition that if a case becomes justiciable only between trial and entry of judgment, the justiciability somehow “relates back” to the time of trial, rectifying a lack of subject matter jurisdiction at the time of trial. The court can find no other authority persuasively supporting Smith’s contention that the court can ignore a lack of subject matter jurisdiction prior to its entry of judgment if subject matter jurisdiction has somehow attached between trial and the entry of that judgment. However, as the court will explain more fully below, the court finds that subject matter jurisdiction existed at the time the complaint in this matter was filed, existed at the time of trial, and continues to exist at this time. a. Standing i. Constitutional and prudential requirements. “Standing is a threshold matter that, if absent, prevents [a] Court from exercising jurisdiction.” Campbell v. Minneapolis Pub. Hous. Auth., 168 F.3d 1069, 1073 (8th Cir.1999). “The Supreme Court has often emphasized that a lawsuit in federal court is not a forum for the airing of interested onlookers’ concerns, nor an arena for public-policy debates.” Mausolf, 85 F.3d at 1301 (citing Valley Forge Christian College v. Americans United for Separation of Church and State, Inc., 454 U.S. 464, 473, 102 S.Ct. 752, 70 L.Ed.2d 700 (1982)). Instead, the court must find that the litigant has standing before it may reach the merits of his or her claim. Campbell, 168 F.3d at 1073. As the Eighth Circuit Court of Appeals explained in Campbell, The Constitution requires a party to satisfy three elements before it has standing to bring suit in federal court: injury in fact, causation, and redressability. See [Steel Co. v. Citizens for a Better Env't, 523 U.S. 83, -, 118 S.Ct. 1003,] 1016-17 [140 L.Ed.2d 210 (1998)] [ (1998) ].[T]he party invoking federal jurisdiction[ ] has the burden of establishing these three elements. See Lujan v. Defenders of Wildlife, 504 U.S. 555, 561, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992). Campbell, 168 F.3d at 1073; accord Olympus Aluminum Prods., Inc. v. Kehm Enters., Ltd., 930 F.Supp. 1295, 1306 (N.D.Iowa 1996). A somewhat more detailed explanation of these constitutional requirements was set forth in Mausolf v. Babbitt, 85 F.3d 1295 (8th Cir.1996): First, the would-be litigant must have suffered an “injury in fact”; that is, an “invasion of a legally protected interest which is (a) concrete and particularized ... and (b) actual or imminent, not conjectural or hypothetical....” Lujan, 504 U.S. at 560, 112 S.Ct. at 2136 (internal quotation marks and citations omitted). Second, the would-be litigant must establish a causal connection between the alleged injury and the conduct being challenged. Ibid. Third, he must show that the injury is likely to be redressed by a favorable decision. Id. at 561, 112 S.Ct. at 2137; see Friends of the Boundary Waters Wilderness v. Thomas, 53 F.3d 881, 886 (8th Cir.1995) (standing requires (1) injury in fact, (2) causation, and (3) redressability). Mausolf, 85 F.3d at 1301. The prudential requirement of standing involves satisfaction of the “zone-of-interests test.” Friends of Boundary Waters Wilderness v. Dombeck, 164 F.3d 1115, 1125 (8th Cir.1999). This zone-of-interests test “considers whether the interest sought to be protected by the complainant is arguably within the zone of interests to be protected or regulated by the statute or constitutional guarantee in question.” Id. (quoting Bennett, 520 U.S. at 163, 117 S.Ct. 1154, in turn quoting Association of Data Processing Serv. Orgs., Inc. v. Camp, 397 U.S. 150, 153, 90 S.Ct. 827, 25 L.Ed.2d 184 (1970)) (internal quotation marks omitted). More. specifically, “‘[wjhether a plaintiffs interest is arguably protected by the statute within the meaning of the zone-of-interests test is to be determined not by reference to the overall purpose of the Act in question ... but by reference to the particular provision of law upon which the plaintiff relies.”’ Id. (quoting Bennett, 520 U.S. at 175-76, 117 S.Ct. 1154, with alterations and quotations omitted). ii. Smith’s standing. The court concludes that Smith satisfies the initial three-prong test of standing, and indeed satisfied it at the time his complaint was filed through the time of trial. As to his “injury in fact,” Campbell, 168 F.3d at 1073; Mausolf, 85 F.3d at 1301, the court finds first that Smith has suffered an “invasion of a legally protected interest which is ... concrete and particularized,” Mausolf, 85 F.3d at 1301, in that, as a recipient of Medicaid assistance, he has a legally protected interest in receiving coverage pursuant to “reasonable standards ... for determining eligibility for and the extent of medical assistance under the plan.” 42 U.S.C. § 1396a(a)(17). That interest here is “concrete and particularized,” Mausolf, 85 F.3d at 1301, because Smith seeks coverage for a specific treatment. Furthermore, the invasion of the interest is “actual or imminent, not conjectural or hypothetical,’’ id, because Smith is in the middle, indeed near the end, of the sex reassignment process, having already undergone several stages of the process — including a hysterectomy and removal of his ovaries, breast reduction, hormone treatment, “real life” test, and psychotherapy — and coverage has already been denied for some of those previous steps in the process. In short, this is not a situation in which the plaintiffs desire for Medicaid coverage for a specific treatment has appeared out of the blue and there is some hypothetical or contingent element to the demand; rather, Smith seeks coverage to complete a process that has been going forward for years, even if the exact timing of the final phase of treatment were somehow uncertain— which, according to Dr. Satterfield’s supplemental testimony, it should not now be. Although Smith cannot assert a claim for reimbursement for prior stages of sex reassignment surgery in this litigation— because he has not made such a claim here — in the context of a continuing process of sex reassignment for which some prior claims for reimbursement have already been denied, and in the absence of any indication that the IDHS will change its policy of denying such claims, the court finds that Smith’s injury is certainly “imminent, not conjectural or hypothetical.” Id. (emphasis added). As to the second prong of the test for standing, Smith can show “causation,” Campbell, 168 F.3d at 1073; Mausolf, 85 F.3d at 1301, in that the challenged conduct is the defendant’s denial of coverage for the final stage of Smith’s sex reassignment surgery, and the injury causally connected to that conduct is that Smith is denied completion of the surgery, a purportedly medically necessary treatment for his condition. Third, Smith can show that a favorable decision is likely to “redress” his injury, id; Mausolf, 85 F.3d at 1301, because the decision will remove the final impediment to his obtaining the final stage of his sex reassignment surgery. Thus, the remaining issue for determining Smith’s standing to pursue this litigation is the prudential one of whether he satisfies the “zone-of-interest test.” See Friends of Boundary Waters Wilderness, 164 F.3d at 1125. The court finds that the interest Smith seeks to protect is at least arguably within the zone of interests to be protected or regulated by 42 U.S.C. § 1396a(a)(17). Id. Although Donald Herman, the Administrator of the Division of Medical Services for the IDHS, testified that he perceived the purpose of the Iowa Medicaid program to be to provide the broadest package of benefits available to the most people possible with the resources available, Trial Transcr., Testimony of Donald Herman, Vol. II, p. 367,11. 4-8, whether Smith’s interest satisfies the zone-of-interests test “ ‘is to be determined not by reference to the overall purpose of the Act in question ... but by reference to the particular provision of law upon which the plaintiff relies.’ ” Id. (quoting Bennett, 520 U.S. at 175-76, 117 S.Ct. 1154, with alterations and quotations omitted). The interest of the particular provision here, 42 U.S.C. § 1396a(a)(17), as this court explained in its ruling on summary judgment, is to impose “reasonable standards” for determining eligibility for and the extent of medical assistance consistent with the objective of Medicaid to provide medical services to the needy, the aged, the blind, and the disabled. See Smith, 24 F.Supp.2d at 963; 42 U.S.C. § 1396a(a)(17) (stating that the “reasonable standards” must be “consistent with the objectives of this subchapter” and take into account income eligibility requirements); see also Hern v. Beye, 57 F.3d 906, 910-11 (10th Cir.) (“Second, Colorado’s restriction violates 42 U.S.C. § 1396a(a)(17) because it is inconsistent with the basic objective of Title XIX — to provide qualified individuals with medically necessary care.”), cert. denied sub nom. Weil v. Hern, 516 U.S. 1011, 116 S.Ct. 569, 133 L.Ed.2d 494 (1995). Smith’s interest in completion of his sex reassignment surgery falls within this “zone of interests,” because he asserts he is being unreasonably denied coverage for sex reassignment surgery even though he falls within the group of persons Medicaid is designed to protect and the treatment sought is medically necessary and consistent with the medical assistance otherwise provided. Therefore, Smith has “standing” to pursue his claims here. b. Ripeness i. Constitutional and prudential requirements. Both the Eighth Circuit Court of Appeals and the United States Supreme Court have explained that [t]he basic rationale of the ripeness doctrine is to prevent the courts, through the avoidance of premature adjudication, from entangling themselves in abstract disagreements over administrative policies, and also to protect the agencies from judicial interference until an administrative decision has been formalized and its effects felt in a concrete way by the challenging parties. California v. FCC, 124 F.3d 934, 943 (8th Cir.1997) (quoting Missouri v. Cuffley, 112 F.3d 1332, 1337 (8th Cir.1997), with internal quotations and citations omitted), rev’d in part on other grounds, AT&T Corp. v. Iowa Utilities Bd., 525 U.S. 366, -, 119 S.Ct. 721, 142 L.Ed.2d 835 (1999); Ohio Forestry Ass’n, Inc. v. Sierra Club, 523 U.S. 726, -, 118 S.Ct. 1665, 1670, 140 L.Ed.2d 921 (1998) (quoting Abbott Labs. v. Gardner, 387 U.S. 136, 148-49, 87 S.Ct. 1507, 18 L.Ed.2d 681 (1967)); see also Southwestern Bell Tel. Co. v. FCC, 153 F.3d 523, 556 (8th Cir.1998) (quoting California v. FCC). To show that claims are “ripe” for federal judicial determination, a plaintiff must show two things: (1) that there is a sufficiently concrete case or controversy within the meaning of Article III of the Constitution; and (2) that prudential considerations justify the present exertion of federal judicial power. See McKenzie v. City of White Hall, 112 F.3d 313, 316 (8th Cir.1997); Von Eye v. United States, 92 F.3d 681, 684 (8th Cir.1996) (same); accord Ohio Forestry Ass’n, Inc., 523 U.S. at -, 118 S.Ct. at 1670 (describing the two requirements as a showing of the “fitness of the issues for judicial decision” and the “hardship to the parties of withholding court consideration,” citing Abbott Labs., 387 U.S. at 149, 87 S.Ct. 1507); Texas v. United States, 523 U.S. 296, -, 118 S.Ct. 1257, 1260, 140 L.Ed.2d 406 (1998) (citing the same factors as the Court in Ohio Forestry Ass’n). The first requirement is satisfied if “the ‘conflicting contentions of the parties ... present a real, substantial controversy between parties having adverse legal interests, a dispute definite and concrete, not hypothetical or abstract.’” Cuffley, 112 F.3d at 1337 (quoting Babbitt v. United Farm Workers Nat’l Union, 442 U.S. 289, 298, 99 S.Ct. 2301, 60 L.Ed.2d 895 (1979), in turn quoting Railway Mail Ass’n v. Corsi, 326 U.S. 88, 93, 65 S.Ct. 1483, 89 L.Ed. 2072 (1945)). The second requirement involves consideration of “the ‘hardship to the parties of withholding court consideration.’” Ohio Forestry Ass’n, Inc., 523 U.S. at -, 118 S.Ct. at 1670; Texas v. United States, 523 U.S. at -, 118 S.Ct. at 1260. Some of the specific factors the Supreme Court has required courts to consider in determining whether the requirements of “ripeness” have been met are the following: (1) whether delayed review would cause hardship to the plaintiffs; (2) whether judicial intervention would inappropriately interfere with further administrative action; and (3) whether the courts would benefit from further factual development of the issues presented. Ohio Forestry Ass’n, Inc., 523 U.S. at -, 118 S.Ct. at 1670. In another recent decision, the Supreme Court noted that “[a] claim is not ripe for adjudication if it rests upon contingent future events that may not occur as anticipated, or indeed may not occur at all.” Texas v. United States, 523 U.S. 296, -, 118 S.Ct. 1257, 1259, 140 L.Ed.2d 406 (1998) (quoting Thomas v. Union Carbide Agric. Prods. Co., 473 U.S. 568, 581, 105 S.Ct. 3325, 87 L.Ed.2d 409 (1985), in turn quoting 13A Charles A. Wright, Arthur R. Miller & Edward H. Cooper, Federal Practice & PROCEDURE § 3532, p. 112 (1984)) (internal quotation marks omitted). ii. Ripeness of Smith’s claim. For many of the same reasons the court found that Smith has standing to pursue his claim, the court finds that he has satisfied the first prong of the “ripeness” determination, a concrete case or controversy within the meaning of Article III of the Constitution. See McKenzie, 112 F.3d at 316. The conflicting contentions of Smith and the Director regarding coverage of sex reassignment surgery present a “real, substantial controversy between the parties having adverse legal interests,” and that dispute is “definite and concrete, not hypothetical or abstract,” Cuffley, 112 F.3d at 1337, again, because Smith is in the middle or near the end of an on-going, multi-stage process of sex reassignment, the defendant has already denied coverage for prior stages of the process, and the defendant shows no sign of changing Iowa Medicaid policy to deny coverage for sex reassignment surgery. Prudential considerations also weigh in favor of finding that the present dispute is “ripe,” because delay would cause hardship to Smith, in that it would delay the final stage of sex reassignment surgery for which he was imminently or is now “ready”; judicial intervention would not inappropriately interfere with further administrative action, because there is no indication that the IDHS currently or ever intends to revisit its regulations prohibiting coverage for sex reassignment surgery; and the factual development of the issues after trial on the merits is more than adequate to address the issues, so that no further factual development is required. See Ohio Forestry Ass’n, Inc., 523 U.S. at -, 118 S.Ct. at 1670 (requiring consideration of these factors). Although the Director asserted that this case is not ripe for adjudication, because it rests upon contingent future events that may not occur as anticipated, or may never occur, see Texas v. United States, 523 U.S. at -, 118 S.Ct. at 1259, because Smith’s physicians had not certified him as “ready” for the final stage of sex reassignment surgery at the time of trial, that defect has evaporated with Dr. Satterfield’s supplemental certification that Smith is indeed now “ready” for a phalloplasty. Therefore, the court finds that this matter is “ripe” for adjudication. 3. Disposition of the motion to dismiss Thus, the court finds that Smith now has — and had throughout this litigation— “standing” to pursue the claim presented here, and that his claim is — and has been — “ripe” for adjudication. Because the “bedrock requirement” of a case or controversy- — upon which the Director’s standing and ripeness challenges were based — has been satisfied, see Mausolf, 85 F.3d at 1300 (“From this bedrock requirement [of a case or controversy] flow several doctrines — e.g., standing, mootness, ripeness, and political question — which state fundamental limits on federal judicial power in our system of government.”) (internal quotation marks and citations omitted), the Director’s motion to dismiss for lack of subject matter jurisdiction will be denied. The court will therefore turn to the merits of Smith’s claim for coverage by the Iowa Medicaid program of the final stage of his sex reassignment surgery. B. The Merits In asserting that Smith is not entitled to relief on the merits, the Director first asks the court to reconsider its ruling on summary judgment, which determined that there was a legal basis for Smith’s claims and that there were genuine issues of material fact on the proof of those claims. In addition, the Director’s counsel declared succinctly his position at trial that the defense would prove that sex reassignment surgery is very far from an accepted medical procedure and very far from anything that the state Medicaid program ought to provide. Smith argues that there is indeed a legal basis for his claims, and that sex reassignment surgery is not “experimental,” but a recognized treatment for his gender identity disorder, that it is “medically necessary” for his condition, and that he is now “ready” for such surgery. 1. The legal basis for Smith’s claims a. The Director’s arguments In his trial brief, the Director asserted that the court should reconsider its conclusions, rendered in the order denying the Director’s motion for summary judgment, that Smith has a cause of action under 42 U.S.C. § 1983 based on rights defined in 42 U.S.C. § 1396a(a)(17) and 42 C.F.R. § 440.230(b), (c) and (d). The Director reiterates the argument that the “extent” of medical assistance discussed in § 1396a(a)(17) refers to the “extent” of the assistance, that is, to deductibles and coverage limits, not to the scope of services covered by a state plan. To the extent the statute has been interpreted to refer to services provided, the Director contends the statute provides no judicially enforceable standard, particularly when viewed in conjunction with the purpose of Title XIX to render coverage “as far as practicable under the conditions in such state.” 42 U.S.C. § 1396. The Director also reiterates the argument that 42 C.F.R. § 440.230(b) does not further define any right to services under § 1396a(a)(17), because it does not purport to implement that subsection of the statute, but instead implements § 1396a(a)(10), citing 42 C.F.R. § 440.200(a)(1). He argues further that 42 C.F.R. § 440.230(b) does not address what services are provided, only the amount, duration, and scope of the services the state has decided to provide to persons in the medically needy category. The Director also argues that sex reassignment surgery is not a service that must be provided to medically needy individuals under 42 C.F.R. § 440.230(c) and § 440.220, and that 42 C.F.R. § 440.230(c) and (d) have no basis in the statute. b. Analysis As this court explained in its summary judgment ruling, In 1965, the federal Medicaid program was created when Congress added Title XIX to the Social Security Act, 42 U.S.C. § 1396 et seq., “for the purpose of providing federal financial assistance to states that choose to reimburse certain costs of medical treatment for needy persons.” Harris v. McRae, 448 U.S. 297, 301, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980). Although participation in the Medicaid program is entirely voluntary, once a state elects to participate, it must comply with federal statutory and regulatory requirements. Id. at 301, 100 S.Ct. at 2671; Weaver v. Reagen, 886 F.2d 194, 197 (8th Cir.1989) (“Although a state’s participation [in the Medicaid program] is voluntary, once a state chooses to participate in the program it must comply with federal statutory and regulatory requirements.”). Federal and state governments finance Medicaid programs jointly, but state governments actually administer the programs. Wilder v. Virginia Hosp. Ass'n, 496 U.S. 498, 502, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990). Pursuant to Title XIX, participating states must provide financial assistance for medical services to the “categorically needy,” which include the aged, blind, disabled, and needy individuals with dependent children. 42 U.S.C. § 1396a(a)(10)(A); see Beal v. Doe, 432 U.S. 438, 440 n. 1, 97 S.Ct. 2366, 53 L.Ed.2d 464 (1977). Although not required to do so, participating Medicaid states may also opt to provide medical services to the “medically needy.” 42 U.S.C. § 1396a(a)(10)(C); see Beal, 432 U.S. at 440 n. 1, 97 S.Ct. 2366. “Medically needy” individuals are those “who do not qualify for some forms of federal assistance but who nonetheless lack the resources to obtain adequate medical care.” Hodgson v. Board of County Com'rs, County of Hennepin, 614 F.2d 601, 606 (8th Cir.1980). Iowa participates in the Medicaid program and provides services to both the categorically needy and the medically needy. “If a State elects to include the medically needy in its Medicaid plan, it has the option of providing somewhat different coverage from that required for the categorically needy.” Harris, 448 U.S. at 301 n. 1, 100 S.Ct. 2671 (citation omitted). Smith, 24 F.Supp.2d at 960 (footnote omitted). The categories of medical services that are available to “medically needy” individuals, at the option of the state, are specified in 42 U.S.C. § 1396a(a)(10)(C)(iv), and specifically defined in § 1396d(a). The parties do not dispute that Smith belongs to, and receives Medicaid services as, a “medically needy” individual. They also do not dispute that the general categories of medical services covered by the Iowa Medicaid program and provided to individuals in the medically needy coverage group include inpatient hospital services, physician’s services, prescribed drugs, and prosthetic devices. Nor do they dispute that, but for an administrative regulation prohibiting coverage for such services, sex reassignment surgery would fall within the covered categories of services for medically needy individuals. Section 1396a(a)(17) provides, in pertinent part, as follows: A State plan for medical assistance must— (17) ... include reasonable standards (which shall be comparable for all groups ...) for determining eligibility for and the extent of medical assistance under the plan which (a) are consistent with the objectives of this subchapter [1396a].... 42 U.S.C. § 1396a(a)(17). The regulation upon which the court relied as further defining the statutory right, 42 C.F.R. § 440.230, provides as follows: (a) The plan must specify the amount, duration, and scope of each service that it provides for— (1) The categorically needy; and (2) Each covered group of medically needy. (b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose. (c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition. (d) The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures. 42 C.F.R. § 440.230. Numerous courts, including our own circuit court of appeals, have held that this subsection of the Medicaid statute, § 1396a(a)(17), and this regulation, 42 C.F.R. § 440.230, taken together, put boundaries on the discretion of the states to limit the services provided to “medically needy” persons if such states have decided to extend coverage to that category of persons. See, e.g., Weaver v. Reagen, 886 F.2d 194, 197-98 (8th Cir.1989) (noting the substantive limitations on determination of services to be covered in 42 C.F.R. § 440.230(a)-(d), , and observing that, “[m]oreover, the state’s plan for determining eligibility for medical assistance must be ‘ “reasonable” and “consistent with the objectives” of the Act.’ Beal v. Doe, 432 U.S. 438, 97 S.Ct. 2366, 2371, 53 L.Ed.2d 464 (1977) (quoting 42 U.S.C. § 1396a(a)(17)).”); accord Planned Parenthood Affiliates of Mich. v. Engler, 73 F.3d 634, 637 (6th Cir.1996) (“Although it is true that Title XIX requires only that the state exercise its discretion in creating a medical plan in a manner ‘reasonable’ and ‘consistent with the objectives’ of Medicaid, 42 U.S.C. § 1396a(a)(17) (1988); Beal v. Doe, 432 U.S. 438, 444, 97 S.Ct. 2366, 2371, 53 L.Ed.2d 464 (1977), a state ‘may not arbitrarily deny or reduce the amount, duration, or scope of a required service ... to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition.’ 42 C.F.R. § 440.230(c) (1994). Abortions, as we discussed above, fall within several of Medicaid’s mandatory categories of care. The question, then, is whether Section 109a discriminates in its coverage of abortions on the basis of a patient’s diagnosis and condition.”); Hope Med. Group for Women v. Edwards, 63 F.3d 418, 425 (5th Cir.1995) (after noting that “Title XIX specifically provides that participating states must establish ‘reasonable standards’ that are ‘consistent with the objectives’ of the Act,” citing 42 U.S.C. § 1396a(a)(17), the court found that “HCFA regulations promulgated under Title XIX provide additional guidance in assessing the reasonableness of a state restriction on the medical services offered through its Medicaid program,” citing 42 C.F.R. § 440.230, and concluding that “[a] participating state may, therefore, choose to limit the provision of particular medical procedures or treatments as long as the restriction complies with § 440.230.”), cert. denied sub nom. Foster v. Hope Med. Group for Women, 517 U.S. 1104, 116 S.Ct. 1319, 134 L.Ed.2d 471 (1996); Hern v. Beye, 57 F.3d 906, 910-11 (10th Cir.) (“Second, Colorado’s restriction violates 42 U.S.C. § 1396a(a)(17) because it is inconsistent with the basic objective of Title XIX — to provide qualified individuals with medically necessary care. The purpose of Medicaid as stated in the Act is to enable states to provide medical treatment to needy persons ‘whose income and resources are insufficient to meet the cost of necessary medical services.’ Id. § 1396 (emphasis added). This circuit, as well as several other courts, has interpreted Title XIX and its