Federal Appeals Court Ruling on West Virginia Medicaid Ban on Gender Surgery Could Reshape State Policies Nationwide
Why It Matters
A federal appeals court decision upholding West Virginia’s ban on Medicaid coverage for adult gender-transition surgeries is sending ripples across the country, with legal experts warning that states — including those in the Pacific Northwest — may now feel emboldened to impose similar restrictions on how public funds are spent on such procedures.
Washington State, which currently includes gender-affirming procedures in its Medicaid coverage policies, could face pressure to revisit those policies as the legal landscape shifts following a wave of court rulings and federal directives that push in the opposite direction.
What Happened
The 4th U.S. Circuit Court of Appeals issued a ruling in March in Anderson v. Crouch, overturning a lower court decision that had struck down West Virginia’s ban on Medicaid coverage for adult gender-transition surgeries as discriminatory.
The three-judge appeals panel ruled unanimously that West Virginia’s policy applies only to specific procedures and does not target a protected class such as sex. The judges wrote that it is not irrational for a legislature to decline to fund what they described as experimental procedures that may encourage individuals to reject their biological sex.
The ruling follows directly from the U.S. Supreme Court’s December 2024 decision in U.S. v. Skrmetti, which upheld Tennessee’s ban on gender-transition procedures for minors. The Supreme Court subsequently vacated several lower court rulings — including the original West Virginia decision — and returned them for reconsideration in light of the Tennessee case. The plaintiffs in the West Virginia case have filed a request for a rehearing before the full appeals court panel.
By the Numbers
- An estimated 152,000 transgender adults are enrolled in Medicaid nationally, according to the Williams Institute at UCLA.
- Fewer than half of those individuals live in states that guarantee Medicaid coverage for gender-transition procedures.
- 27 states explicitly include gender-transition procedures in Medicaid coverage policies; 11 states explicitly ban such coverage for people of all ages, according to the Movement Advancement Project.
- About 29% of LGBTQ+ people live in states that exclude Medicaid coverage for such procedures.
- At least seven other states have faced lawsuits over banning or limiting insurance coverage for gender-transition procedures, according to Reuters.
Zoom Out
The 4th Circuit ruling technically sets binding precedent only in states within that circuit, but legal experts say its influence is likely to reach far beyond those borders. Elana Redfield, federal policy director at the Williams Institute, said the decision “could encourage states to adopt more, broader bans, including Medicaid bans, even for adults.”
The ruling also aligns with a series of executive orders issued by President Donald Trump directing federal agencies to recognize only a biological, binary definition of sex. Oklahoma lawmakers are currently advancing legislation that would prohibit Medicaid funds from covering adult gender-transition care and bar any public money from being used by organizations or individuals to pay for such procedures. That bill passed the state Senate and an 11-2 vote in a House oversight committee.
Carmel Shachar, an assistant clinical professor at Harvard Law School’s Health Law and Policy Clinic, called the West Virginia ruling “a significant early case in the post-Skrmetti landscape” and described it as “a sign of which way the wind is blowing right now when it comes to state policies.” She added that private insurers who are reluctant to cover such procedures may now feel more comfortable declining to do so following the ruling.
In Texas — which already bans Medicaid coverage for gender-transition procedures for all ages — advocates report an ongoing “chilling effect,” with patients receiving insurance denial letters and some mental health providers dropping patients out of concern over potential legal liability under a Texas attorney general opinion issued last month.
The federal legal direction is increasingly consistent: the Supreme Court has given states room to restrict public funding for gender-transition procedures, and lower courts appear to be following that lead. For states like Washington that maintain broad Medicaid coverage for such procedures, the question is whether legal or legislative challenges will follow. For context on other policy shifts affecting Washington State, see how lawmakers’ budget decisions are already reshaping public services in the state.
What’s Next
The plaintiffs in Anderson v. Crouch have requested a rehearing before the full 4th Circuit, which could alter or affirm the panel’s decision. Legal analysts expect additional states to file similar restrictions or face new lawsuits as courts continue to interpret the boundaries set by Skrmetti.
Oklahoma’s bill still requires a full House vote and a governor’s signature before becoming law. If enacted, it would make Oklahoma the latest state to explicitly ban public funds from covering adult gender-transition procedures — adding to a list that legal advocates warn is growing. The federal government’s evolving posture on funding and regulation in health-adjacent policy areas suggests further changes may be forthcoming at both the state and national level.
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