A federal appeals court is once again weighing whether West Virginia can exclude gender-affirming surgery from its Medicaid program for transgender adults. On December 9, the U.S. Court of Appeals for the Fourth Circuit heard re-arguments in Anderson v. Crouch, a case that could shape access to transgender healthcare across several states.
The rehearing follows a directive from the U.S. Supreme Court earlier this year. In June, the Court vacated the Fourth Circuit’s 2024 ruling that had blocked West Virginia’s Medicaid exclusion and ordered the appeals court to reconsider the case in light of its decision in United States v. Skrmetti. That Supreme Court ruling upheld a Tennessee law restricting gender-affirming care for minors, though it did not directly address adult healthcare or Medicaid coverage.
The lawsuit began in 2020 when transgender Medicaid beneficiaries, including Christopher Fain and Shauntae Anderson, challenged West Virginia’s policy barring coverage for gender-affirming surgical procedures. While the state Medicaid program covers hormones, mental health care, and other related treatments, surgery is categorically excluded. Plaintiffs argue that exclusion discriminates against transgender people based on sex and gender identity.
In August 2022, a federal district court ruled in favor of the plaintiffs, finding that the exclusion violated the Equal Protection Clause, the Affordable Care Act’s nondiscrimination provision, and the Medicaid Act. The Fourth Circuit affirmed that ruling in April 2024, concluding that West Virginia could not single out gender-affirming care for exclusion while covering comparable medical treatments for other conditions.
That victory was short-lived. After the Supreme Court’s decision in Skrmetti, West Virginia asked the justices to intervene. Rather than issuing a final ruling, the Court sent the case back to the Fourth Circuit for reconsideration under the new legal framework.
During oral arguments this month, attorneys for West Virginia argued that the Medicaid exclusion reflects medical judgment and fiscal discretion, not discrimination. State lawyers claimed federal law does not require coverage of gender-affirming surgery and suggested the Supreme Court’s recent reasoning limits how courts evaluate transgender discrimination claims.
Attorneys for the plaintiffs strongly disagreed. They emphasized that Skrmetti addressed care for minors, not adults, and argued that denying medically necessary surgery to transgender adults remains unlawful. Lambda Legal attorneys told the court that West Virginia’s policy targets transgender people in practice and strips them of care recommended by their doctors.
Judges on the panel questioned both sides closely, probing whether the exclusion functions as a neutral coverage decision or an intentional denial based on transgender status. They also examined how recent Supreme Court rulings affect civil rights protections under Medicaid and federal healthcare law.
The Fourth Circuit did not indicate when it will issue a decision. If the court reverses its earlier ruling, West Virginia’s Medicaid ban could be reinstated. A reaffirmation, however, would restore protections for transgender adults seeking gender-affirming surgery and influence Medicaid policies throughout the Fourth Circuit, which includes Maryland, Virginia, North Carolina, and South Carolina.
For now, the case remains one of the most consequential legal battles over transgender healthcare access still unfolding in the federal courts.
