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By Robert B. Barnett, Jr., J.D.
A Wisconsin federal court has agreed to class certification and to extend a preliminary injunction prohibiting the Wisconsin Medicaid agency from enforcing two exclusions denying coverage for transgender surgeries and drug treatments pending the individual's lawsuit.
A group of Wisconsin transgender individuals wanting gender-confirming surgeries to cure their gender dysphoria were entitled to certification as a class in their suit, which was brought against the Wisconsin Medicaid agency seeking to overturn a state administrative rule excluding transgender surgeries from Medicaid coverage. In effect, the suit raises the question whether a state may refuse medical procedures based on sex rather than on medical efficacy. The court also agreed to extend a preliminary injunction the transgender individuals had obtained to stop the Wisconsin Medicaid agency from enforcing the exclusion. The injunction does not necessarily entitle the transgender individuals to the gender-confirming surgeries; it merely requires that Wisconsin evaluate their requests on medical necessity pending completion of the suit (Flack v. Wisconsin Department of Health Services, April 23, 2019, Conley, W.).
Background. Several transgender individuals living in Wisconsin suffered from gender dysphoria and anxiety. They received hormone therapy that did not cure the dysphoria. Their physicians recommended gender-confirming surgery and related procedures, which the physicians said were medically necessary to treat their ailments. They sought coverage for the procedures through Medicaid. And, in all cases, the Wisconsin Department of Health Services denied those claims, citing two Wisconsin code provisions. Those two provisions, which are part of a long list of exclusions from coverage, apply to "Drugs, including hormone therapy, associated with transsexual surgery or medically unnecessary alteration of sexual anatomy or characteristics" and "Transsexual surgery." The individuals brought suit in Wisconsin federal court against the Medicaid agency, asking the court to invalidate the two exclusions. The court granted their request to preliminarily enjoin the Medicaid agency from enforcing those exclusions. They then filed two motions: (1) a motion certify a class and (2) a motion to amend the preliminary injunction.
Removal impact. Prior to addressing the issues raised in the motion, the court addressed the potential financial impact on Wisconsin's Medicaid budget if the exclusions were removed. The Medicaid agency contended that the impact would be severe, if it were suddenly required to pay for numerous expensive treatments. The court, however, seemed to side with the transgender individuals' medical expert, who testified that it would involve minimal short-term costs and possible long-term savings from the reduced ongoing costs in treating these ailments that the surgeries were designed to eliminate.
Class certification. The court evaluated whether the class certification requirements of numerosity, commonality, typicality, and adequacy were satisfied. Because the claims were so similar, with only minor differences in some of the ancillary treatments some individuals sought, the court rather easily satisfied itself that those requirements were satisfied. The only real question was numerosity. The court concluded, that approximately 5,000 Wisconsin Medicaid enrollees were transgender. Some unknown subset of that group would suffer from gender dysphoria, which should be too many to join in a single lawsuit. Thus, numerosity was satisfied.
As for commonality, among the common issues to be resolved were: (1) whether the exclusions violated an existing prohibition on sex discrimination in federally funded programs, (2) whether the exclusions violated the Medicaid Act's availability or comparability requirements, and (3) whether the exclusions violated the Equal Protection Clause.
As for adequacy, on the representation side, the various lawyers pursuing this claim were experienced in class actions and in transgender issues. In a final matter, after concluding that Rule 23(a) was satisfied, the court had to satisfy itself that one of Rule 23(b) conditions was also met. It chose Rule 23(b)(2), which provides that class certification is appropriate where a single injunction or declaratory judgment would provide relief to each member of the class. As a result, the court certified a class of all transgender individuals who were enrolled in Wisconsin Medicaid, who have or who will be diagnosed with gender dysphoria, and who have or who will seek surgical or medical services to treat gender dysphoria.
Preliminary injunction. The transgender individuals made the same arguments for extending the preliminary injunction through the end of the case that they made in obtaining the injunction initially. The court, therefore, once again looked to evidence of (1) irreparable harm, (2) inadequate legal remedies, (3) likelihood of success, and (4) balance of harms. The court concluded that the first two requirements had met been met by a combination of the agency's refusal to provide coverage and the high costs of the treatment outside of Medicaid. "Overwhelming evidence" exists, the court said, that the surgeries are medically necessary. The larger medical community already recognizes the surgeries as valid aspects of medical care. Even the agency acknowledged that gender dysphoria is a serious medical condition. As a result, a blanket exclusion was likely to harm class members. Furthermore, having surgery later on, after trial, would not cure the harm that these transgender individuals will experience while they wait.
Turning to the likelihood of success, the transgender individuals had only to establish that their chances of success were better than negligible. Such a likelihood had clearly been established, the court said. As for the balance of harms, the agency argued that extending the injunction would force it to pay for surgeries that cost between $240,000 and $960,000. The transgender individuals argued that, given the relatively small number of Wisconsin Medicaid recipients who need the surgery, the costs amount to nothing more than a rounding error in the state's $3.9 billion portion of annual Medicaid spending. The court also harkened back to the medical expert's testimony that the long-term effects might save the state money. Although the court agreed to extend the injunction, questions remained about the scope, with the agency contending that some of the ancillary procedures that the transgender individuals sought, such as electrolysis and voice therapy, were not denied because of the exclusions. The court agreed with the agency, reminding everyone that an extension of the injunction did not mean that the individuals were entitled to all the services they sought; it meant only that Wisconsin was required to base its determination on medical necessity.
Bond. As a final matter, the court ruled that the transsexual individuals were not required to post a bond as a condition of obtaining the injunction because the potential outlays by Wisconsin were likely to be insufficient to justify it.
The case is No. 18-cv-309-wmc.
Attorneys: Joseph J. Wardenski (Relman, Dane & Colfax PLLC) for Cody Flack. Steven Carl Kilpatrick, Wisconsin Department of Justice, for Wisconsin Department of Health Services.
Companies: Wisconsin Department of Health Services
MainStory: TopStory CaseDecisions CMSNews MedicaidNews EligibilityNews MICNews ProgramIntegrityNews WisconsinNews
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19 arrests at Celtic vs Rangers
Event Commander at yesterdays powderkeg semi-final Chief Superintendent Andy Bates announced today that there were less than 20 arrests in and around Hampden, in a relatively trouble free day.
The majority of the arrested parties found themselves being held on alleged Sectarian Breach of the Peace charges, there were also fixed penalty notices issued as well.
Chief Superintendent Andy Bates said "As usual the vast majority of the 50,000 fans were here to enjoy the game and support their respective team; they deserve credit for their excellent behaviour. However, again, it is the minority of fans who spoiled the occasion by, for example, setting off flares and singing sectarian songs."
With an increased police presence and the intelligent use of social media to help travelling fans arrive safely at co-ordinated train stations and bus stops, the chance of rival fans confronting each other was diminished.
Before the match, the atmosphere around Hampden was electric as Scottish football's two great rivals faced each other for the first time in three years, with a place in the League Cup final at stake.
Celtic will face Dundee Utd after they ran out comfortable winners in a considerably incident free semi-final.
With broadcasters outside of the UK eager to screen the match, the SPFL estimated that there could have been a worldwide audience of 125 million viewers, countries such as Australia, Asia, USA and countries throughout Europe snapped up television rights.
Chief Superintendent Andy Bates said in a breakdown of the arrests, "11 men will appear at Glasgow Sheriff Court, Feb 2nd, five have been reported to Procurator Fiscal and 3 were issued with fixed penalty notices."

subset: commoncrawl


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Super cute mermaid lucky dolls.
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text: SuperDave 530 #41 Posted April 27, 2017 I'm in. I don't really have a preference on courses. Don't know any there. I have looked a Windy Knoll. It is west of Columbus, but it looked nice. Sent from my SM-G920V using MyGolfSpy mobile app 1 Share this post Link to post Share on other sites


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Try Painless Facial at Click House
Many women are still reluctant to do facial treatment because of the pain. This is not wrong, because there are still many beauty clinics that offer facial treatments with the risk of pain during the process of removing acne and squeezed blackheads.
However, now you don't need to be afraid anymore, because now you can find beauty clinics that offer painless facial. One of them that you should try is Click House. Located in the Melawai area, South Jakarta, this beauty clinic offers Signature Modern Facial, a type of modern facial without squeezing blackheads and acne, but uses light energy that is converted into heat energy to stimulate collagen to make skin healthier, smoother and tighter.
Click House The Beauty itself consists of three floors with a choice of sharing and VIP rooms. If you choose treatment in the VIP room, then only you in the room doing treatment and there's no other patient.
Before doing treatment, there will be a question and answer session first to find out your face condition. Usually, the therapist will ask if you are menstruating, use night cream, have skin allergies or not. After that, you will be asked to wait.
After that, you will be asked to lie on the bed. At first, therapy will cleanse your face using milk cleanser to clean up your makeup remnants. Then, the dirt remnants will removed using cotton. Afterward, the therapist will cleanse your face using face wash.
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Facial cleansing is followed by using a special scrub for acne-prone skin. The last stage of facial cleansing uses facial toner which gives a fresh feeling with a relaxing aroma. All cleaning products are specially formulated by Click House which is divided for normal and acne-prone skin.
Then, your face will be evaporated using a facial steamer so that your face pores open and start lifting blackheads with special tools. The shape of this tool has a small head tip and is able to suck up small blackheads all over the face with no pain. By painstaking and thorough, the therapist suck up the area of your face where there are many blackheads, such as on your cheeks, nose, chin, and forehead area. It only took about five minutes, until finally all the blackheads on your face lifted up.
Signature Modern Facial is only priced at Rp 250 thousand for one treatment. If you come with a friend or your partner, the price will be Rp 400 thousand for both of you for one treatment. Signature Modern Facial is good for you who want to clean your face thoroughly, especially lifting stubborn blackheads without pain. And if you have allergic skin, be sure to consult with a doctor at Click House who is always ready to help you.
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So far, my newest approach with my red horse is still proving to be effective. As I've learned to expect, effective doesn't mean without learning experiences. Which is what I am now choosing to call them. Previously, I might have referred to them as mistakes, wrong turns, or maybe even something with swear words.
What helps me the most with this new ability to see some incidents as learning experiences is my Sunshine inspired perspective of not taking his choices and actions personally. Of course, I still have work to do here, but I am so much better at it! Fortunately, I work with horses, and will never run out of learning opportunities.
Since I have been interacting with my red horse more from the gentle strength of my direct leadership, there have been a few times that his protests have resulted in the lead rope being pulled out of my hand and him running off. After a deep breath, I walk after him and pick the rope back up. Well, ok, sometimes it's more than one deep breath, and he might be running for a couple minutes. Nothing big and dramatic after the initial act of leaving. The difference now as opposed to what was logged in our history is that we go back to what we were doing before Sunshine decided to leave. Before, it would have resulted in us being done for the day, as catching him could take quite some time. This is where the swear words could appear.
Noticing that after each detour from my plan, Sunshine releases tension in some form and gets better, has really been a big help in not taking his antics personally or feeling like I have failed. This has allowed the feeling of partnership with him to grow. We even have moments that he feels soft and connected while on the lunge line. This happens even after the much smaller protests he expresses. It's almost as if he tests the edges and then releases tension as he trusts in the security of the boundary. It's really cool to witness.
Rhythm is proving to be our friend in the lunging endeavors. On the line, I am only asking and holding space for Sunshine to move forward and encourage him to maintain a steady rhythm. Most of the time, there is a chaos to his movement that I think is a direct reflection of what's in his mind. The wonderful thing that is happening is that as he relaxes into a steadier rhythm, his tendency to bend away from the center of the circle diminishes. I have tried to "tell" him to bend the other way. No surprise that is when the leaving was most likely to take place. No pushing of this horse! Being brave enough to watch what happens and try something different if the result isn't desirable is really the only way that I can have fun playing with Sunshine. And, fun is what I will consider success!
Many thanks to my red horse for being such a great teacher. I am still listening and learning……..and occasionally retrieving a runaway.


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Zambia Day Three
Waking up for our last day, we hopped into our swim suits and headed to the Devil's Pool. For those of you who don't know, on the Zambian side of...Read more
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We flew from Johannesburg to Livingstone in the morning knowing getting through customs would take some time once we touched down. **Things to note should anyone reading this ever wish...Read more


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Scottish Care has released a new report which explores recruitment and retention of individuals working in the care sector.
The report findings show:
However, it also highlights:
The report was launched at an event in Glasgow yesterday (March 15) attended by over 100 staff from across the health and social care sector including a number of those working at the front line of care delivery.
Speaking at the launch, CEO of Scottish Care, Dr Donald Macaskill (pictured), said: "Our new research shows the need to consider how we attract people to enter the care sector and to pursue a fulfilling career within it. Whilst more needs to be done through education and careers advice to encourage young people to work in social care, the findings show an increase in older people applying for care jobs so we must also make sure that employment opportunities are suitably flexible and promoted appropriately amongst people of all ages and backgrounds.
"Yet concerningly, we know that a huge number of people are leaving the sector at an early stage of their employment, predominantly because they are not suitable for the work or it wasn't what they expected it to be. Whilst working in care is undoubtedly challenging, it is also a hugely rewarding and skilled profession with lots of opportunities and we must therefore ensure that there is better awareness of all that comes with a career in care –to better recognise the importance of this profession but also to ensure we have the right people delivering complex care to our loved ones and that we have a sustainable care sector going forward. Without a committed workforce, we won't have social care services."
Scottish Care's National Workforce Lead, Katharine Ross, added: "A career in care is not the same for everybody but it needs to be available to everybody. This report captures the employment journey of so many committed, dedicated and skilled individuals of different ages, backgrounds and experiences working in care homes and care at home organisations across Scotland.
"However, it also shows the reality facing the care sector:
"Only by acknowledging these realities will we be able to shut the door through which dedicated and skilled individuals are flooding out from, and create conditions where people enter, stay, develop and thrive in the care sector. It is the only way to ensure the development of a rights-based, dignified social care system for the tens of thousands of older people receiving care in their own home, or in a care home."
Read the 4Rs: The open doors of recruitment and retention in social care


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Weekly Forex Technical Analysis : 5 – 9 August 2019
ForexInfoBook presents the weekly Forex technical analysis of GOLD (XAUUSD), GBPUSD and USDJPY for 5 to 9 August 2019. During the past two weeks the price action prediction made in our previous analysis on GOLD was very accurate. The Brexit uncertainty continues to make GBP trading relatively risky and the break of 1.2400 rendered our long recommendation invalid. Similarly the support @ 1.1100 was broken on EURUSD which invalidated the long recommendation. With major risk events (ECB, BOE, Fed interest rates and NFP) behind us now, the following trading recommendations may be considered for trading this week.
GOLD Technical Analysis
Even though the FED interest rate decision was USD positive, USD weakened on back of Trade tariffs imposed on China. The NFP data was on expected lines and USD continues to be driven about by trade talks and tariffs for now. GOLD has formed a well defined upward channel with the obvious target seen at the 50% Fibonacci level at 1483.7 – While the break of last month's high at 1453 is expected this week, the upper trend line of the channel may provide some reversal opportunities. With GOLD's bullish bias and no expected USD positive events/news in the horizon, it would be very risky to short GOLD at these levels. When GOLD approaches 1484, aggressive traders can consider short positions on reversal confirmation.
A better approach to trading gold for this week would be to enter long positions near the lower trend line in the zone of 1401 to 1407. Close below 1400 should be seen as a break of the bullish move. Stoploss may be placed in near 1395 to avoid stop grabber moves. Traders going long at these levels can consider holding for target of 1483 this month. This recommendation may be considered invalid if the upper trend line is broken and 1483 is reached prior to the price pulling back to 1400 levels.
GBPUSD Technical Analysis
With the October deadline approaching and the probability of a "No Deal" Brexit increasing, GBPUSD is approaching its multi year lows of 1.2000 levels. We may see the pair supported at 1.2000 levels considering the very large short positions built up over past few weeks. In the absence of any GBP positive news and no progress in Brexit deal, any bounce will be seen as a shorting opportunity by traders. A bounce from 1.2000 level is expected to give further momentum for the shorts to break through the strong 1.2000 levels and take the pair to down to its No-Deal Brexit target of 1.1500-1.1300 zone.
The first attempt to test 1.2000 support provides traders with a good low risk, high reward long trade opportunity over the next two weeks.
USDJPY Technical Analysis
USD weakened on announcement of further trade tariffs imposed on China. The NFP data was on expected lines and did not provide any reason for USDJPY to take support from its support at 107 levels. USD continues to be driven about by trade talks and tariffs for now – with break of 106, the pair may be able to reach its multi year low of 104.57 during this week.
USDJPY is likely to find support at this level and traders can consider going long with stoploss below 103.90 and targets of 109. The trade setup offers excellent risk:reward for patient traders.