Fourth Circuit Rules North Carolina and West Virginia Can’t Deny Transgender People Coverage for Medical Care

“All we wanted is equal access to healthcare, but we were denied just because we are transgender.”

(RICHMOND, VA – April 29, 2024) -- Today, the U.S. Court of Appeals for the Fourth Circuit affirmed two lower court rulings ordering North Carolina and West Virginia to end their discriminatory exclusions for coverage of gender-affirming medical care for transgender people in both states.

The full panel of the Circuit Court ruled in favor of transgender plaintiffs in two separate lawsuits, finding both states’ denial of coverage for medical care to be discriminatory and unconstitutional. One lawsuit, Kadel v. Folwell—brought by Lambda Legal and Transgender Legal Defense & Education Fund (TLDEF) with HWG LLP and McDermott, Will & Emery LLP—challenged North Carolina’s categorical exclusion of coverage for gender-affirming medical care for transgender government employees and their dependents enrolled in the state health plan. The other lawsuit, Anderson (previously Fain) v. Crouch—filed in 2020 by Lambda Legal, Nichols Kaster, PLLP, and the Employment Law Center, PLLC— challenged West Virginia’s exclusion of coverage for gender-confirming surgical care for low-income transgender people enrolled in Medicaid.

“West Virginia’s denial of medically necessary care just because of who I am was deeply dehumanizing. I am so relieved that this court ruling puts us one step closer to the day when Medicaid can no longer deny transgender West Virginians access to the essential healthcare that our doctors say is necessary for us,” said plaintiff Shauntae Anderson, a Black transgender woman and West Virginia Medicaid participant.

“I am pleased with this powerful court victory not only for myself but for all other state employees who have been discriminated against across North Carolina. As government employees, all we want is equal access to healthcare, but we were denied just because we are transgender. I’m relieved the court found this discrimination unlawful, and hope North Carolina officials will finally stop their wasteful fight to deny us our rights and will now stand on the side of equality,” said Julia McKeown, an associate professor in the College of Education at North Carolina State University.

Ezra Cukor, TLDEF Senior Counsel, said, “To be denied coverage for life-saving health care simply because you are transgender is degrading and humiliating. Trans people only want to get the same coverage for their health care needs as their co-workers. The court saw how blatantly discriminatory and wrong North Carolina’s policy was and found that the state employee health plan broke federal law, and we are delighted with this outcome.”

Lambda Legal Senior Counsel Tara Borelli, the lead lawyer on both lawsuits, said, “We are pleased with the Court’s decision, which will save lives. It confirms that discriminating against transgender people by denying critical medical care is not only wrong but unconstitutional. No one should be denied essential health care, but our clients in both cases were denied coverage for medically necessary care prescribed by their doctors just because they’re transgender.”

Nichols Kaster Partner Anna Prakash, co-counsel in Anderson v. Crouch said, “This life-saving decision affirms what our clients, the district court, and the law have said all along: transgender people should not be denied healthcare based on who they are. I am so proud of our clients, co-counsel, and advocacy community for fighting to make clear that this type of discrimination is dangerous, wrong, and unconstitutional.”

Lambda Legal Counsel and Health Care Strategist Omar Gonzalez-Pagan said, “The court’s decision sends a clear message that gender-affirming care is critical medical care for transgender people and that denying it is harmful and unlawful. Overwhelming research has found that gender-affirming care significantly improves the overall health and wellbeing of transgender people, both youth and adults. By contrast, denying access to this care has detrimental effects on the health of trans people, which can include worsening dysphoria, depression, anxiety, and even self-harm. We hope this decision makes it clear to policy makers across the country that health care decisions belong to patients, their families, and their doctors, not to politicians.”

This ruling sets a clear precedent not just for North Carolina and West Virginia but to all jurisdictions within the Fourth Circuit, including South Carolina, where legislators are considering a discriminatory healthcare ban.

On Anderson (previously Fain):
In 2020, Lambda Legal, along with Nichols Kaster, PLLP and The Employment Law Center, PLLC, filed Anderson (previously Fain) v. Crouch on behalf of Christopher Fain and subsequently Shauntae Anderson, both Medicaid participants. The case was also filed on behalf of several state employees, which led to a 2022 settlement with The Health Plan of West Virginia, Inc., which removed the exclusion on coverage for gender-confirming care in its state employee health plan. In August 2022, a federal District Court Judge Robert C. Chambers ruled that West Virginia’s Medicaid program could no longer discriminate by excluding coverage for gender-confirming surgical care for transgender West Virginia Medicaid participants.

On Kadel:
In 2019, Lambda Legal and TLDEF, along with HWG LLP and McDermott, Will & Emery LLP, filed the lawsuit, Kadel v. Folwell, on behalf of several current and former state employees and their dependents after the North Carolina State Health Plan (NCSHP), the state employee health plan, denied coverage for their medically necessary gender-affirming care. In June 2022, the federal trial court ruled in favor of the eight transgender plaintiffs. The trial judge ruled that the NCSHP and North Carolina state employers violated the Equal Protection Clause of the U.S. Constitution and Title VII of the Civil Rights Act of 1964, by unlawfully discriminating based on sex and transgender status.

Fourth Circuit Appeals:
In 2023, state officials in North Carolina and West Virginia appealed to the Fourth Circuit the two lower court decisions that ruled against the states in both lawsuits. The Court heard oral arguments in both cases in two separate three-judge panel hearings in 2023, one in January for Kadel v Folwell and one in March for Anderson v. Crouch. In September 2023, the Fourth Circuit heard both cases together en banc, by a full panel of the Court.

Read the decision.
To learn more about Kadel v. Folwell, visit here: Kadel v. Folwell - Lambda Legal
To learn more about Anderson v. Crouch, visit here: Anderson v. Crouch - Lambda Legal

Tyleis Davidson, Lambda Legal,

Jonathan Adams, Transgender Legal Defense and Education Fund,

Lambda Legal is a national organization committed to achieving full recognition of the civil rights of lesbians, gay men, bisexuals, transgender people and everyone living with HIV through impact litigation, education and policy work.

The Transgender Legal Defense and Education Fund (TLDEF) is committed to ending discrimination based upon gender identity and expression and to achieving equality for transgender people through public education, test-case litigation, direct legal services, and public policy efforts. To learn more about TLDEF’s work, visit

Updated on May 3, 2024