Equal Protection in Healthcare

Facts of the Case

Maxwell Kadel, a transgender man employed by the University of North Carolina, participated in the North Carolina State Health Plan (NCSHP), a state-operated insurance program providing coverage for state employees and their dependents. Mr. Kadel sought treatments for gender dysphoria recommended by his health care providers.

The NCSHP explicitly excluded all treatments related to “sex changes or modifications.” This prohibition applied to all participants in the plan, regardless of individualized care assessments by their health care team. Similarly, the Medicaid plan in West Virginia denied coverage for any gender-affirming surgeries. The same treatments that were rejected under the gender dysphoria diagnosis were approved when identified with different diagnostic codes.

The plaintiffs in both West Virginia and North Carolina argued that these exclusions violated their rights. They sought to have the exclusions declared unconstitutional and to obtain coverage for the treatment of gender dysphoria. The states maintained that their health care plans were lawful, nondiscriminatory, and based on legitimate concerns about cost and scientific evidence.

The district courts found in favor of the plaintiffs in both North Carolina and West Virginia, concluding that the health care plan violated the Equal Protection Clause and, in the case of West Virginia, also violated the Medicaid and Affordable Care Acts. The courts granted summary judgment in favor of the plaintiffs, prohibited the states from enforcing the exclusions, and ordered the reinstatement of coverage for medically necessary treatments for gender dysphoria. The defendants subsequently appealed the decision to the U.S. Court of Appeals for the Fourth Circuit, and the case consolidated for the opinion below.

Ruling and Reasoning

Among arguments, the appellants claimed that the district court misapplied evidentiary rules when it excluded portions of their expert’s opinions. The district court constrained the experts to the specific areas where they had expertise, e.g., an endocrinologist was not permitted to testify on the diagnosis of gender dysphoria but was permitted to testify on puberty-blocking medication. The U.S. Court of Appeals for the Fourth Circuit evaluated the admissibility of experts using Federal Rule of Evidence 702 (2011). Rule 702 requires that testimony be based on sufficient facts or data, that it is the product of reliable principles and methods, and that the expert has reliably applied these principles and methods to the facts of the case. The court found that the district court did not abuse its discretion in excluding the expert testimonies deemed speculative, lacking sufficient peer-reviewed backing, or outside the experts’ specific areas of expertise.

The appellants claimed that the exclusion of gender-affirming care was justified by the need to save costs and uncertainties about the treatments’ effectiveness. The Fourth Circuit Court of Appeals upheld the district courts’ rulings that excluding coverage for gender-affirming care violated the Fourteenth Amendment. The court cited Grimm v. Gloucester County School Board, 972 F.3d 586 (4th Cir. 2020), and Bostock v. Clayton County, 590 U.S. 644 (2020), for the position that gender identity has been established as a protected characteristic under the Equal Protection Clause. The court determined that the policies at issue discriminated on the basis of sex and transgender status. It found that the exclusion was discriminatory because it specifically denied coverage for treatments related to gender transition while covering the same treatments for other conditions.

Additionally, the court noted that financial considerations do not qualify as a valid government interest for discrimination and that substantial medical evidence supports the necessity of gender-affirming treatments for individuals diagnosed with gender dysphoria.

Dissent

Several judges wrote dissenting opinions. Judge Harvie Wilkinson expressed concerns about constitutional arguments for gender-affirming care, advocating for resolution through the democratic process. He framed gender dysphoria as an uncertain and scientifically debated matter. Judge Julius Richardson said that the policies were not inherently discriminatory and fell within the state’s authority to make decisions based on medical diagnoses rather than on sex or transgender status. Judge Marvin Quattlebaum criticized excluding expert testimony and cautioned against making definitive declarations in unsettled scientific debates. Collectively, the dissenting opinions expressed concern about the broader implications of the majority’s ruling on the balance between state policymaking authority and judicial oversight.