Judge Roger L. Gregory, an appointee of President Clinton, wrote for the majority that the restriction was “clearly discriminatory” on the basis of both sex and gender.
“In this case, differentiating based on diagnosis is teeth This is because “gender dysphoria is so closely related to transgender status that it is virtually indistinguishable from transgender status,” Gregory wrote.
The majority also ruled that West Virginia’s policy violated the anti-discrimination provisions of the Affordable Care Act, a finding that would have far-reaching implications for other states’ Medicaid systems. become.
This is the second ruling in favor of transgender rights this month by the 4th Circuit, a once conservative court that has been a trailblazer in the field of transgender rights. The court said for the first time that trans students have the right to use the bathroom that corresponds to their gender identity, and recognized gender dysphoria as a protected disability for the first time. A court said earlier this month that federally funded middle schools cannot ban transgender 13-year-olds from playing on girls’ track and field teams.
The ruling could be appealed to the Supreme Court, which recently allowed Idaho to enforce its ban on gender-affirming care for minors. But conservative-led courts have been reluctant to weigh in on the issue, leaving several Fourth Circuit decisions upholding transgender rights in place. Additionally, courts typically wait until there is a disagreement between circuits before getting involved.
Both decisions divided the Fourth Circuit along ideological lines, with Democratic-appointed judges joining the majority opinion and Republican-appointed judges dissenting. Judge Jay Richardson, a Trump appointee, led the dissent against Monday’s ruling, saying there is no role for federal courts in policing what treatments health plans decide to cover. I wrote.
Richardson said the majority opinion “treats these incidents as new fronts on which this conflict must be waged. But not all battles are part of a larger war.” Majority In its haste to defend the plaintiffs’ cause, today’s results overstep the bounds of the law.”
Richardson said it’s important that trans patients receive the same coverage for the same conditions as other patients. For example, she said, trans patients with uterine cancer can undergo a hysterectomy under these plans.
“Different coverage for treatments for different diagnoses…is based on medical judgment of biological reality,” he wrote. “States can reasonably determine that certain gender dysphoria services are not cost-effective, in part because they question the medical effectiveness and necessity of the services.”
Other states have banned hormone treatment and surgery for trans minors. Some also limit care for transgender adults. Several other states have similar laws governing insurance coverage for transition-related treatment.
In West Virginia, transgender Medicaid recipients challenged the state’s program, which has outlawed “gender reassignment surgery” since 2004. In North Carolina, state officials challenged their own requests. In 2018, surgical treatment of gender dysphoria, a clinical diagnosis of a disconnection between a person’s sex and their sex at birth, was excluded.
Both states argued that the coverage limitations were not biased, only a matter of cost. They argued that trans patients were only entitled to the same medical care as everyone else, but not to specialized care.
“There is no service that applies to a cisgender person that does not apply to a transgender person who meets the same criteria,” West Virginia attorney Caleb David told the appellate court judges during oral argument. David added that the state has decided to offer psychiatric and hormonal treatment for gender dysphoria, but not just surgery.
Advocates for trans patients said there is no medical justification for drawing the line there when the state covers such procedures for other conditions. They also said economic explanations were questionable because so few people undergo gender reassignment surgery.the “It’s a drop in the bucket,” Tara Borelli, an attorney with Lambda Law Firm, said during oral argument. However, she argued that even if the cost is significant, the cost of public health insurance “must be shared.” We cannot put it on the backs of vulnerable minorities. ”
The court agreed, stating that cost savings cannot justify applying the same treatment to health concerns other than gender dysphoria. For example, Gregory said that under these plans, “cisgender people do You can get coverage for certain gender reassignment surgeries, including breast reconstruction for cancer patients after mastectomy.
North Carolina began targeting gender-affirming care in 2017, but discontinued it the year after Republican Dale Falwell became state treasurer. North Carolina State University professor Julia McCune transitioned in 2016, several years after fully transitioning after a lifetime of being “stubborn about her gender” but limited in her ability to express it. accepted the job. She spent months preparing for her surgery, which she ended up paying in full along with all other treatment costs.
“It’s like having the rug pulled out from under you,” she said. “In some ways, it’s worse than going in knowing you’re going to be rejected.” Rather than delay her surgery, she dipped into her retirement savings and was able to do so. “I was lucky,” she called herself.
McCune grew up in rural Florida and spent years pretending to be a man for fear of social and professional exclusion. Participating in the lawsuit meant exposing himself to hate mail from strangers.
“In an ideal world, I just wanted to move on with my life,” she said after the surgery. “At the same time, I feel a moral obligation to help those who cannot speak up for themselves, who are at risk of being laid off, or who have dependents on state health plans who need medical treatment. .”
Twenty-one Republican-led states asked the court to rule against the plaintiffs, highlighting disagreements over what physical interventions should be available to transgender youth. However, most major health plans and the federal government cover gender reassignment treatment, and it is supported by mainstream medical associations. Research shows that very few people, including those who started treatment as teenagers, regret the transition or attempt to reverse the changes.
Seventeen Democratic-led states and the District of Columbia state that “experience has shown that protecting access to gender-affirming care can improve health outcomes for transgender populations at little cost.” asked the court to rule on this application.
correction
An earlier version of this article reported that the insurance plan at issue covered mastectomies for cancer patients, but not trans women. The plan covered mastectomies for all cancer patients, but not for trans men who wanted their breasts removed to treat gender dysphoria.
