Cases & Developments

Opinion affirming judgments of the district courts. Appellees in cases consolidated on appeal, transgender individuals who are beneficiaries of either the North Carolina State Health Plan for Teachers and State Employees (NCSHP) or the Medicaid program in West Virginia, brought equal protection and Medicaid Act and ACA claims against their respective States and relevant officials, challenging the exclusion of coverage for medically necessary services for treatment of gender dysphoria. The district courts granted summary judgment in favor of the appellees and enjoined enforcement of the coverage exclusions. In affirming summary judgment in favor of appellees on their equal protection claims, the Fourth Circuit found that the exclusions of treatments for gender dysphoria, though they target only a subset of transgender individuals, discriminate on the basis of a proxy for gender identity and do so facially. Further, because some patients are eliminated from coverage of certain types of treatments (e.g., mastectomies or chest-reconstruction surgeries) based on their sex assigned at birth and gender stereotypes about how men and women should present, the court found this was also sex discrimination. The court then found that this treatment could not survive intermediate scrutiny because the States’ anecdotal evidence challenging only some of appellees’ contentions was insufficient to show that the treatments in this developing area of medicine are ineffective. The court also held that these exclusions violate the Medicaid Act’s availability and comparability provisions and the ACA’s anti-discrimination provision.