Federal Appeals Court Rules Against Transgender Care Exclusions in North Carolina and West Virginia

The 4th U.S. Circuit Court of Appeals ruled 8-6 on Tuesday that West Virginia and North Carolina's refusal to cover certain gender-affirming health care for transgender people with government-sponsored insurance is discriminatory. The case, which involves coverage of gender-affirming care by North Carolina's state employee health plan and the coverage of gender-affirming surgery by West Virginia Medicaid, is likely headed to the U.S. Supreme Court.

In North Carolina, a trial court ordered the state employee health plan to cover medically necessary services, including hormone therapy and some surgeries, for transgender employees and their children in June 2022. In West Virginia, a federal judge ruled in August 2022 that the state's Medicaid program must provide coverage for gender-affirming care for transgender residents. The West Virginia Attorney General plans to appeal the rulings to the Supreme Court.

The 4th Circuit found the coverage exclusions to be overtly discriminatory on the basis of sex and gender identity. "Discrimination against transgender people is discrimination based on sex and gender identity," the court stated in its ruling. The decision follows a previous ruling by the 4th Circuit that West Virginia's transgender sports ban violates Title IX.

Why this matters: The ruling is a significant victory for transgender rights and access to essential health care amid ongoing legal battles and legislative efforts to restrict gender-affirming care across the country. The case highlights the ongoing debate over the coverage of medically necessary care for transgender individuals and could set a precedent for similar cases in other states.

West Virginia and North Carolina appealed separate lower court rulings that had found the denial of gender-affirming care to be discriminatory and unconstitutional. The states argued that being transgender is not an illness and that they are trying to best utilize limited resources. However, the 4th Circuit rejected these arguments, stating that the coverage exclusions are not substantially related to an important government interest.

Shauntae Anderson, a Black transgender woman and West Virginia Medicaid participant, called her state's refusal to cover her care "deeply dehumanizing." West Virginia Attorney General Patrick Morrisey announced his office's intention to appeal the ruling to the Supreme Court, stating, "This decision, from a court dominated by Obama- and Biden-appointees, cannot stand. We will take this up to the Supreme Court and win."

Key Takeaways

• 4th Circuit ruled West Virginia, North Carolina's refusal to cover transgender care is discriminatory
• Rulings order coverage of gender-affirming care in NC state health plan and WV Medicaid
• Court found coverage exclusions overtly discriminatory based on sex and gender identity
• Ruling is a victory for transgender rights and access to essential health care
• WV, NC plan to appeal rulings to the Supreme Court