Court upholds state's authority to prioritize taxpayer funds for proven, essential medical care
West Virginia Attorney General JB McCuskey announced today that the Fourth Circuit Court of Appeals reversed a lower court ruling and held that West Virginia Medicaid may exclude coverage for gender-affirming surgeries and that the state’s policy does not violate the Equal Protection Clause, the Affordable Care Act, or the Medicaid Act. This decision is a major win for the state and its Medicaid program.
This case, Anderson v. Crouch, is part of a years-long national legal fight over whether states can exclude gender-affirming care from Medicaid and insurance coverage.
“This is a big win for West Virginia taxpayers who pay the bill for Medicaid—a much needed and utilized program. As good stewards of taxpayer dollars, the state should not be footing the bill for unproven, non-essential medical procedures,” Attorney General McCuskey said. “Simply put, the Constitution does not compel states to fund sex reassignment surgeries. Every dollar spent on these unproven procedures takes away funding that could be used to treat cancer, heart disease, and diabetes. I’m pleased the Fourth Circuit finally agrees that our policy does not discriminate and provides the best service for all the state’s Medicaid participants.”
The case arose from a challenge to West Virginia’s decision not to reimburse Medicaid beneficiaries for surgical procedures to treat gender dysphoria. The plaintiffs alleged the exclusion violated the Equal Protection Clause of the U.S. Constitution, the Affordable Care Act, and the Medicaid Act. A district court had sided with the plaintiffs and enjoined the state from enforcing its policy. The Fourth Circuit Court of Appeals initially affirmed that ruling, but the U.S. Supreme Court vacated the decision and remanded the case back for reconsideration after its ruling in United States v. Skrmetti, which upheld states’ authority to make policy decisions about medical interventions.
On remand from the Supreme Court, the Fourth Circuit decided the case differently. The court held that West Virginia’s policy excluding coverage for “sex change” surgeries does not facially classify individuals based on sex or transgender status, and thus does not violate the Equal Protection Clause. Instead, the exclusion classifies based on medical diagnosis and applies evenhandedly to all Medicaid recipients. The court also confirmed that West Virginia Medicaid had legitimate reasons for the exclusion, including concerns about cost, medical efficacy, and the safety of the procedures.
The Fourth Circuit also held that West Virginia’s Medicaid policy does not violate the Affordable Care Act. The Court confirmed that West Virginia Medicaid’s coverage decisions are based on medical criteria, not a patient’s gender identity. The Court further said the plaintiffs could not enforce the Medicaid Act through litigation.
Deputy Solicitor General and Special Counsel for the State of West Virginia Caleb David presented oral argument before the Fourth Circuit Court of Appeals in December.
Read the decision here.
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