The Fourth Circuit Court of Appeals issued a unanimous ruling on March 10 that allows West Virginia to exclude gender-affirming surgery from its Medicaid benefits. The decision came from a three-judge panel and restores a policy that a prior Fourth Circuit decision had struck down. The case traces back to litigation brought by Lambda Legal challenging the state’s exclusion from both Medicaid and state employee plans.
At the center of the dispute are legal theories about equal treatment under federal law and the authority of states to set limits on taxpayer-funded services. The panel relied heavily on recent Supreme Court precedent when returning the matter to the lower court, producing an opinion that many legal observers say broadens the logic used to evaluate restrictions on transgender healthcare.
What the court decided and who wrote the opinion
The three-judge panel—comprised of Judges Paul Victor Niemeyer, Julius Ness Richardson, and Allison Jones Rushing—voted unanimously to reinstate West Virginia’s Medicaid exclusion. All three judges were appointed by Republican presidents, with Niemeyer nominated by George H.W. Bush and both Richardson and Rushing nominated by Donald Trump. In an opinion authored by Judge Richardson, the court endorsed the view that legislatures may rationally decide not to fund certain procedures and even framed part of the rationale around the idea that states may seek to “encourage citizens to appreciate their sex.” The opinion also leans on the Supreme Court’s Skrmetti decision from June 2026, which addressed state bans on gender-affirming care for minors.
Legal background and procedural history
The litigation began with Anderson v. Crouch, filed in 2026 by Lambda Legal on behalf of two Medicaid participants challenging exclusions of gender-affirming care. In April 2026, an earlier Fourth Circuit ruling found in favor of the plaintiffs, holding that plans that cover medically necessary treatments for some diagnoses but exclude the same treatments when the diagnosis is unique to transgender patients violate the Equal Protection Clause, the Medicaid Act, and the Affordable Care Act. After the Supreme Court’s Skrmetti opinion, however, the high court sent Anderson v. Crouch back to the Fourth Circuit for reconsideration and vacated and remanded a related case, Kadel v. Folwell.
How the Supreme Court’s ruling affected the case
The panel cited Skrmetti repeatedly, treating its reasoning as a framework applicable beyond minors to adults seeking gender-affirming treatments. The Supreme Court’s ruling had held that states could prohibit certain treatments for transgender youth; the Fourth Circuit panel extended aspects of that logic to justify West Virginia’s refusal to pay for surgical procedures for adults through Medicaid. Dissenting voices and advocacy groups argue that equating a diagnosis unique to transgender people with a neutral medical condition overlooks the discriminatory effect of excluding care targeted at a specific population.
Reactions and broader implications
West Virginia Governor Patrick Morrisey issued a statement celebrating the ruling as a validation of state discretion over public programs and a defense of taxpayer interests. By contrast, Lambda Legal and its counsel, including senior attorney Omar Gonzalez-Pagan, argued that Skrmetti should not dictate the outcome of statutory claims and emphasized that the plaintiffs are adults denied coverage solely because they are transgender. Lambda Legal contends the earlier Fourth Circuit decision was legally correct and that the recent ruling reverses important protections.
Potential ripple effects
Legal analysts warn that the panel’s language—especially the endorsement of a state’s interest in encouraging citizens to “appreciate their sex”—could be cited by other courts or legislatures seeking to limit access to care or to justify related restrictions. Observers point out that the reasoning could be deployed to support limits on insurance coverage, public programs, or other regulations affecting transgender people. At the federal level, agencies have already proposed measures that would curtail access to gender-affirming services for minors and could influence future policy actions; for example, the Centers for Medicare & Medicaid Services (CMS) issued draft notices in December proposing stricter conditions for hospitals that provide care to transgender youth.
The decision has also attracted commentary about how legal doctrine evolves: Justice Elena Kagan noted that the Court’s approach would have been less likely “a mere decade ago,” underscoring how quickly the constitutional and statutory landscape can shift. As multiple similar suits remain active across several states, appellate courts and ultimately the Supreme Court may be asked to clarify whether and how coverage decisions that affect transgender people comport with federal civil-rights and healthcare statutes.
For stakeholders on both sides—patients, advocacy groups, state officials, and insurers—the Fourth Circuit’s March 10 ruling marks a pivotal moment. The case will continue to unfold as plaintiffs press statutory claims, and as litigation in other jurisdictions tests whether this reasoning becomes a broader precedent or encounters limits in later rulings.