A critical court decision on Medicaid coverage in West Virginia this week is troubling legal experts, who say the ruling could further attack access to gender-affirming health care for trans adults.
On Tuesday, the 4th U.S. Circuit Court of Appeals became the first federal appellate court to uphold a Medicaid ban on coverage for surgeries for transgender adults, less than a year after the Supreme Court’s ruling in U.S. v. Skrmetti allowed a Tennessee ban on gender-affirming care for minors to go into effect.
In a unanimous decision, a panel of three Republican-appointed judges overturned a previous decision that found that West Virginia’s 2004 statute violated the Constitution’s equal protection clause.
Instead, the panel ruled that West Virginia’s Medicaid exclusions do not discriminate against transgender people, and rather that the law applies only to specific surgical procedures to alleviate gender dysphoria.
The judges cited two major Supreme Court rulings from last year that curtailed trans and reproductive rights.
“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,” wrote Judge Julius Ness Richardson, citing the Skrmetti decision.
Richardson later cited Medina v. Planned Parenthood South Atlantic, another 2025 Supreme Court decision, which held that individual Medicaid recipients do not have the right to go to court to enforce their rights to choose a provider. The ruling allowed states to exclude Planned Parenthood from their Medicaid programs, part of the Republican Party’s yearslong effort to curb access to abortion care from the reproductive health organization.
“Equal protection is going to be a harder argument to make.”
– Ames Simmons, lawyer and senior teaching fellow at Duke University School of Law
The circuit court’s decision will impact Medicaid coverage in West Virginia, Virginia, Maryland, North Carolina and South Carolina.
But Sasha Buchert, a senior attorney at Lambda Legal, says the ruling “could easily be applied to any eager anti-trans legislator to seize on — and expand categorical bans on trans rights.”
Currently, more than a dozen states prohibit or restrict Medicaid coverage for gender-affirming care. Over 150,000 transgender adults rely on Medicaid, according to an analysis by the LGBTQ+ public policy group Williams Institute, and more than half live in states where coverage for gender-affirming care is limited.
Ames Simmons, a lawyer and senior teaching fellow at Duke University School of Law, said that low income and disabled transgender people have long faced challenges in gaining equal access to Medicaid coverage. But Simmons believes the 4th Circuit’s ruling is essentially allowing a “blanket exclusion” when it comes to coverage for transgender people and is concerned about what precedent this sets up for future legal challenges.
“It suggests that in federal court, any way that we’re trying to challenge bans that have anything to do with healthcare, Skrmetti is going to foreclose the equal protection non discrimination arguments we used to have,” Simmons told HuffPost. “Equal protection is going to be a harder argument to make.”
Already, seven other states, including Florida, Georgia and Arizona, have faced lawsuits for imposing bans and restrictions on Medicaid coverage for gender-affirming care.
Since his return to office last January, President Donald Trump has made curtailing access to gender-affirming care for transgender youth one of his top priorities. Last year, the Justice Department investigated dozens of doctors and clinics that provide gender-affirming care.
In December, the Trump administration proposed rules to prohibit providers from receiving Medicare and Medicaid funds if they provide gender-affirming care such as puberty blockers or hormone therapies to minors.