West Virginia can ban Medicaid coverage for gender-affirming surgery, US court rules

By Daniel Wiessner

March 10 (Reuters) - A U.S. appeals court on Tuesday upheld West Virginia's ban on Medicaid coverage for gender-affirming surgeries, the latest victory for Republican-led states seeking to curb the procedures amid an ongoing national battle over transgender rights.

In a unanimous ruling, a three-judge panel of the 4th U.S. Circuit Court of Appeals in Richmond, Virginia, overturned a judge's decision that the 2004 statute violated anti-discrimination protections under two federal laws as well as the U.S. Constitution's promise of equal protection under the law.

The 4th Circuit panel wrote that the law applies to specific procedures and not to specific individuals, and so it does not unlawfully discriminate against transgender people.

Republican President Donald Trump's administration has joined Republican-led states in seeking to curb gender-affirming treatment and transgender rights more broadly.

More than a dozen U.S. states prohibit or limit Medicaid coverage for gender-affirming care. Medicaid is the joint federal-state health insurance program for low-income people.

The 4th Circuit became the first federal appeals court to uphold such a law, and did so after the U.S. Supreme Court last year rejected a challenge to a Tennessee law that bans gender-affirming treatment for minors.

The full 4th Circuit in 2024 had struck down West Virginia's law as discriminatory, but the Supreme Court last year directed it to reconsider this case and a separate one involving North Carolina, in light of its decision in the Tennessee case.

The three judges on the panel that ruled on Tuesday were appointed by Republican presidents, two by Trump and one by George H.W. Bush. All three had dissented in 2024 when the full 4th Circuit in an 8-6 ruling declared West Virginia's law invalid. They laid out similar reasoning on Tuesday while citing the Supreme Court ruling 70 times over 35 pages.

"It is not irrational for a legislature to encourage citizens to appreciate their sex and not become disdainful of their sex by refusing to fund experimental procedures that may have the opposite effect," Judge Julius Richardson, a Trump appointee, wrote for the court.

The type of surgeries at issue in the West Virginia law generally alter physical characteristics to align with a person's gender identity, including chest reconstruction, genital alteration and facial procedures.

West Virginia Attorney General John McCuskey, a Republican, said the state should not be subsidizing "unproven, non-essential medical procedures."

"Every dollar spent on these unproven procedures takes away funding that could be used to treat cancer, heart disease and diabetes," McCuskey said.

Lambda Legal, an LGBT rights group that represents plaintiff Shauntae Anderson, did not immediately respond to a request for comment.

U.S. District Judge Robert Chambers, an appointee of Democratic former President Bill Clinton, had ruled in favor of Anderson in 2022.

The 4th Circuit last year sent the case involving a similar North Carolina law back to a lower court for further proceedings. At least seven other states including Florida, Georgia and Arizona have faced lawsuits for banning or limiting insurance coverage for gender-affirming care.

Trump has issued a series of executive orders on transgender rights including a proclamation that there are only two sexes, male and female, and a person's sex cannot change. Trump also banned transgender people from the U.S. military.

The Trump administration has proposed barring providers from receiving funds under the Medicare and Medicaid government insurance programs if they provide gender-affirming treatment to minors, prompting lawsuits that are pending.

The Federal Trade Commission, which enforces consumer protection laws, is investigating medical groups over their support for gender-affirming treatments, an action the groups call unlawful retaliation for constitutionally protected speech.