A federal appeals court ruled that West Virginia and North Carolina’s exclusion of certain health care for transgender people with government-sponsored insurance is discriminatory. The Richmond-based 4th U.S. Circuit Court of Appeals found that these exclusions discriminate based on sex and gender identity, and are not substantially related to an important government interest. Specifically, North Carolina’s policy bars treatment or studies related to sex changes, while West Virginia’s policy bars coverage of transsexual surgery. This decision sets a precedent for similar cases across the country, marking the first U.S. Court of Appeals ruling on government-sponsored coverage exclusions of gender-affirming medical care.
The ruling comes after a recent decision by 4th Circuit judges that West Virginia’s transgender sports ban violates Title IX, the federal civil rights law prohibiting sex-based discrimination in schools. West Virginia Attorney General Patrick Morrisey stated that his office plans to appeal the decision, arguing that the court’s ruling, dominated by Obama- and Biden-appointees, cannot stand. North Carolina State Treasurer Dale Folwell also expressed disappointment with the decision, stating that it conflicts with other federal appeals court rulings and poses financial challenges to the State Health Plan. Despite opposition from the states, the majority opinion of the appeals court emphasized that discriminating against gender-affirming care based on cost is not justified.
In North Carolina, a trial court ordered the state plan to cover medically necessary services, including hormone therapy and surgeries, for transgender employees and their dependents. The state plan covers over 750,000 teachers, state employees, retirees, lawmakers, and their dependents. Similarly, a federal judge ruled in August 2022 that West Virginia’s Medicaid program must provide coverage for gender-affirming care for transgender residents. The states’ lawyers argued that treatments for gender dysphoria, excluded from coverage, are not related to gender identity but rather a diagnosis of distress over gender identity. However, the appeals court found that gender dysphoria is closely tied to transgender identity and that coverage exclusions based on this diagnosis discriminate against transgender individuals.
In his opinion, Judge Roger Gregory emphasized the connection between gender dysphoria and transgender identity, stating that exclusions for gender dysphoria treatment indirectly target transgender identity as well. While West Virginia has covered hormone therapy and pharmaceutical treatments for transgender individuals since 2017, the exclusion of surgical treatments for gender-affirming care was found to be discriminatory. After the ruling, West Virginia plaintiff Shauntae Anderson, a Black transgender woman, expressed relief that the court’s decision brings her closer to accessing essential healthcare denied by Medicaid. The case is likely to be appealed to the U.S. Supreme Court, furthering the debate on discrimination in health care coverage for transgender individuals.
