After United States v. Skrmetti and Medina v. Planned Parenthood South Atlantic: Medicaid Exclusions for Gender-Dysphoria Surgeries Survive Equal Protection/ACA Review, and Medicaid Availability/Comparability Duties Lack a Private Cause of Action

I. Introduction

Case: Shauntae Anderson v. William Crouch, No. 22-1927 (4th Cir. Mar. 10, 2026) (published).
Parties: Medicaid beneficiaries diagnosed with gender dysphoria (Plaintiffs-Appellees), led by Shauntae Anderson, sued West Virginia Medicaid officials and the West Virginia Department of Health and Human Resources, Bureau for Medical Services (Defendants-Appellants).
Policy at issue: West Virginia’s Medicaid plan excludes coverage for “transsexual” or “[s]ex change” surgeries while covering many other services and excluding other categories (e.g., “cosmetic procedures”).

Procedural posture: The district court granted summary judgment to Plaintiffs on (1) Equal Protection, (2) § 1557 of the Affordable Care Act, and (3) Medicaid Act “availability” and “comparability” provisions, and enjoined enforcement. The Fourth Circuit’s en banc decision in Kadel v. Folwell, 100 F.4th 122 (4th Cir. 2024) (en banc), had affirmed similar relief, but the Supreme Court vacated and remanded in Folwell v. Kadel, 145 S. Ct. 2838 (2025), and Crouch v. Anderson, 145 S. Ct. 2835 (2025), for reconsideration in light of United States v. Skrmetti, 605 U.S. 495 (2025). While this appeal was pending, the Supreme Court decided Medina v. Planned Parenthood South Atlantic, 606 U.S. 357 (2025), narrowing private enforceability under the Medicaid Act.

Core issues on remand:

  • Whether excluding coverage for surgeries sought to treat gender dysphoria is discrimination on the basis of sex or transgender status under the Equal Protection Clause.
  • Whether the exclusion violates ACA § 1557’s prohibition of discrimination “on the basis of sex” (via Title IX).
  • Whether Medicaid Act “availability” and “comparability” requirements are privately enforceable in federal court.

II. Summary of the Opinion

The Fourth Circuit (Judge Richardson, joined by Judges Niemeyer and Rushing) reversed. It held:

  1. Equal Protection: Under United States v. Skrmetti and Geduldig v. Aiello, 417 U.S. 484 (1974), West Virginia’s exclusion is best characterized as diagnosis-/treatment-use-based, not a facial classification by sex or transgender status. Absent evidence of invidious intent (proxy discrimination), the exclusion is reviewed for rational basis and survives based on cost and medical-efficacy/necessity concerns.
  2. ACA § 1557: Applying Bostock v. Clayton Cnty., 590 U.S. 644 (2020), as explained by the Supreme Court in Skrmetti, the but-for cause of the coverage denial is the non-covered diagnosis/use (gender dysphoria surgery) rather than sex or transgender status; thus no § 1557 violation.
  3. Medicaid Act: Under Medina v. Planned Parenthood South Atlantic, Plaintiffs have no private cause of action to enforce the Medicaid Act’s “availability” (42 U.S.C. § 1396a(a)(10)(A)) and “comparability” (42 U.S.C. § 1396a(a)(10)(B)) requirements. The court exercised discretion to reach the issue despite Defendants’ earlier forfeiture.

The court vacated the injunction and declaratory judgment and remanded with instructions to enter summary judgment for Defendants.

III. Analysis

A. Precedents Cited

1. The remand drivers: United States v. Skrmetti and Medina v. Planned Parenthood South Atlantic

  • United States v. Skrmetti, 605 U.S. 495 (2025): The decisive Equal Protection template. The Fourth Circuit reads Skrmetti to require careful separation between (a) regulating/covering a medical use or diagnosis (e.g., gender dysphoria) and (b) discriminating against a class of persons (sex or transgender status). The opinion adopts Skrmetti’s insistence that “mere reference to sex” does not trigger heightened scrutiny and that plaintiffs must show a facial classification or invidious purpose for proxy discrimination. It also imports Skrmetti’s rational-basis deference in areas of medical/scientific uncertainty (citing Gonzales v. Carhart, 550 U.S. 124 (2007)).
  • Medina v. Planned Parenthood South Atlantic, 606 U.S. 357 (2025): The decisive enforceability template. Medina held that the Medicaid Act’s “any-qualified-provider provision” did not create a privately enforceable right, applying the “rights-creating language” framework of Gonzaga University v. Doe, 536 U.S. 273 (2002), and emphasizing skepticism toward private enforcement of spending-power statutes. The Fourth Circuit extends Medina to the Medicaid “availability” and “comparability” requirements because they share the same structural features: state-plan directives, aggregate-compliance mechanisms (42 U.S.C. § 1396c), and broad state discretion (citing Beal v. Doe, 432 U.S. 438 (1977), and the “reasonability provision,” 42 U.S.C. § 1396a(a)(17)).

2. Equal Protection framework and classification doctrine

  • Baseline equal protection principles: Nordlinger v. Hahn, 505 U.S. 1 (1992), and City of Cleburne v. Cleburne Living Ctr., 473 U.S. 432 (1985), supply the “similarly situated” and default rational-basis structure, while Romer v. Evans, 517 U.S. 620 (1996), is quoted (via Skrmetti) for the necessity of classifications in legislation.
  • Sex discrimination and scrutiny level: Miss. Univ. for Women v. Hogan, 458 U.S. 718 (1982), United States v. Virginia, 518 U.S. 515 (1996), and Nguyen v. INS, 533 U.S. 53 (2001), ground intermediate scrutiny for sex-based classifications and reinforce that recognizing biological differences is “not a stereotype.”
  • Facial classification identification: The opinion relies on Parents Involved in Cmty. Schs. v. Seattle Sch. Dist. No. 1, 551 U.S. 701 (2007); Shaw v. Reno, 509 U.S. 630 (1993); and Adarand Constructors, Inc. v. Pena, 515 U.S. 200 (1995), to define facial classification as distributing burdens/benefits “on the basis of” protected status.
  • Evenhanded application and neutrality: Vacco v. Quill, 521 U.S. 793 (1997), and N.Y.C. Transit Auth. v. Beazer, 440 U.S. 568 (1979), are invoked for the idea that evenhanded laws typically comply with Equal Protection.

3. Proxy discrimination, intent, and disparate impact limits

  • Intent requirement: Pers. Adm'r of Mass. v. Feeney, 442 U.S. 256 (1979), and Washington v. Davis, 426 U.S. 229 (1976), are used to reject a “disparate impact alone” approach; absent overt/covert classification, heightened review requires invidious purpose.
  • When intent may be inferred: Bray v. Alexandria Women's Health Clinic, 506 U.S. 263 (1993), provides the “obvious proxy” concept, but the opinion stresses the high bar: there must be no plausible neutral explanation.
  • Classic proxy/evasion cases: The opinion cites Yick Wo v. Hopkins, 118 U.S. 356 (1886); Guinn v. United States, 238 U.S. 347 (1915); Gomillion v. Lightfoot, 364 U.S. 339 (1960); and Arlington Heights v. Metro. Hous. Dev. Corp., 429 U.S. 252 (1977), to situate proxy intent analysis.

4. The pivotal analogy: Geduldig v. Aiello and its reaffirmations

  • Geduldig v. Aiello, 417 U.S. 484 (1974): The opinion uses Geduldig to treat the Medicaid exclusion as removing one “risk”/use (gender-dysphoria surgeries) rather than excluding a protected class from eligibility. It emphasizes Geduldig’s framing: “pregnant women and nonpregnant persons,” and maps it onto “those seeking excluded diagnoses” versus others.
  • Reaffirmations: The opinion notes Bray v. Alexandria Women's Health Clinic, Gen. Elec. Co. v. Gilbert, 429 U.S. 125 (1976), Nashville Gas Co. v. Satty, 434 U.S. 136 (1977), and Dobbs v. Jackson Women's Health Org., 597 U.S. 215 (2023), as support that a regulation of a sex-linked condition is not automatically sex discrimination for Equal Protection purposes.

5. Rational basis and judicial deference

  • Standard articulation: FCC v. Beach Commc'ns, Inc., 508 U.S. 307 (1993), and Lehnhausen v. Lake Shore Auto Parts Co., 410 U.S. 356 (1973), supply the “any reasonably conceivable state of facts” and “negative every conceivable basis” formulations.
  • Medical uncertainty deference: Gonzales v. Carhart is cited (via Skrmetti) to justify legislative latitude when the evidence base is contested.

6. ACA § 1557, Title IX, and the role of Bostock

  • Fourth Circuit linkage: The opinion relies on Grimm v. Gloucester Cnty. Sch. Bd., 972 F.3d 586 (4th Cir. 2020), for the proposition that Title VII interpretations “guide” Title IX, and thus inform ACA § 1557 (42 U.S.C. § 18116(a)).
  • Bostock v. Clayton Cnty., 590 U.S. 644 (2020): The court adopts Skrmetti’s application of Bostock’s but-for method (“change one thing at a time”) to conclude that changing sex/transgender status does not change coverage outcome when the diagnosis/use remains non-covered.
  • Post-Skrmetti signals: The opinion cites Lange v. Houston Cnty., 152 F.4th 1245 (11th Cir. 2025), as corroborative that Skrmetti’s explanation of Bostock can be dispositive for statutory sex-discrimination claims involving insurance coverage.
  • Limit on pregnancy-related statutory moves: The opinion distinguishes the Pregnancy Discrimination Act and Newport News Shipbuilding & Dry Dock Co. v. EEOC, 462 U.S. 669 (1983), as pregnancy-specific and not a general rule that excluding any sex-linked condition is “sex discrimination” under all statutes.

7. Private enforcement, forfeiture, and party presentation

  • Waiver vs forfeiture: United States v. Olano, 507 U.S. 725 (1993), is used to classify Defendants’ delay as forfeiture, not waiver.
  • Authority to reach antecedent issues: Clark v. Sweeney, 607 U.S. 7 (2025) (per curiam), United States v. Sineneng-Smith, 590 U.S. 371 (2020), U.S. Nat'l Bank of Or. v. Indep. Ins. Agents of Am., Inc., 508 U.S. 439 (1993), and Arcadia v. Ohio Power Co., 498 U.S. 73 (1990), support addressing dispositive predicate questions even if not pressed below.
  • Intervening change in law: Arakas v. Comm'r, Soc. Sec. Admin., 983 F.3d 83 (4th Cir. 2020), and Singleton v. Wulff, 428 U.S. 106 (1976), support reaching issues where Supreme Court law intervenes.
  • Rights-creating language test: Gonzaga University v. Doe and Health & Hosp. Corp. of Marion Cnty. v. Talevski, 599 U.S. 166 (2023), are used (through Medina) to demand “clear and unambiguous” individual-rights focus.

B. Legal Reasoning

1. Recharacterizing the exclusion as diagnosis-/use-based rather than status-based

The opinion’s central move is definitional: the Medicaid plan does not, in the court’s view, deny benefits because someone is transgender or because of sex; it denies coverage for a set of procedures when performed for a particular diagnosis/use (treatment of gender dysphoria) while allowing coverage for similar procedures when performed for other diagnoses (e.g., cancer reconstruction, congenital absence, painful gynecomastia).

This move tracks Skrmetti’s insistence that “medical treatment” includes both (i) the procedure and (ii) the condition for which it is administered. On that understanding, West Virginia is not selecting between “transgender people and non-transgender people,” but between “covered indications and non-covered indications.”

2. Applying Geduldig via Skrmetti: risk exclusion is not automatically class discrimination

The opinion extends Geduldig’s “remove one condition from compensable risks” logic to gender dysphoria surgeries. Even if only transgender individuals seek such surgeries for that diagnosis, the court treats that as insufficient to establish a facial classification or to infer discriminatory intent, absent evidence the diagnosis line is a mere pretext.

3. Rejecting sex-stereotyping as a trigger for heightened scrutiny

The court reads Skrmetti to foreclose elevating scrutiny through a “sex stereotyping” lens when the challenged rule does not classify “covertly or overtly” on sex and there is no showing of invidious purpose. It also emphasizes Nguyen v. INS and United States v. Virginia to characterize the State’s differential treatment as grounded in medical/biological considerations rather than role stereotypes.

4. Rational basis is satisfied by cost and contested medical evidence

Once the exclusion is placed in rational-basis territory, the court treats West Virginia’s asserted rationales as more than enough:

  • Cost containment: finite Medicaid resources justify prioritizing other coverage and avoiding expensive surgeries.
  • Efficacy/necessity uncertainty and risk: the record reflects debate, and Skrmetti instructs deference where science is contested.

Notably, the court offers an additional rhetorical reinforcement: if a State may “reasonably ban” certain treatments (as in Skrmetti), then “of course” it may refuse to pay for them—treating non-coverage as an easier case than prohibition.

5. ACA § 1557: importing Skrmetti’s Bostock application

The opinion acknowledges that § 1557 incorporates Title IX, and that Fourth Circuit precedent (Grimm v. Gloucester Cnty. Sch. Bd.) uses Title VII interpretations to guide Title IX. It then treats Skrmetti’s discussion of Bostock as controlling the proper but-for analysis: changing the patient’s sex does not change the coverage decision if the diagnosis/use remains non-covered. Therefore, sex (or transgender status) is not the but-for cause of the denial.

6. Medicaid Act: no private cause of action after Medina

The court’s Medicaid Act holding is structural: the availability and comparability provisions are framed as requirements for what “state Medicaid plans must provide,” not as individual rights with rights-creating language. They sit in the “Contents” section describing plan terms for federal funding and are enforceable through federal administrative mechanisms (e.g., substantial compliance and funding consequences under 42 U.S.C. § 1396c), which Medina reads as inconsistent with private judicial enforcement.

7. Addressing forfeiture: why the court reached the cause-of-action issue

Even though Defendants did not press the no-cause-of-action argument earlier, the court:

  • classified the lapse as forfeiture (not waiver) under United States v. Olano;
  • invoked the “antecedent and dispositive” doctrine from U.S. Nat'l Bank of Or. v. Indep. Ins. Agents of Am., Inc.;
  • relied on the intervening change in law created by Medina to justify reaching the issue.

C. Impact

1. Immediate doctrinal effects in the Fourth Circuit

  • Equal Protection challenges to Medicaid non-coverage of gender-dysphoria surgeries face rational-basis review when the state frames the policy as diagnosis-/use-based and plaintiffs cannot prove pretext or invidious purpose. The opinion signals that words like “sex change” and “transsexual,” standing alone, do not transform a coverage exclusion into a facial classification of persons.
  • ACA § 1557 coverage disputes will likely track Skrmetti’s but-for causation framing (diagnosis/use as the causal lever), at least where the plan covers the same procedures for other diagnoses for all beneficiaries.
  • Medicaid Act litigation narrows sharply: By extending Medina to §§ 1396a(a)(10)(A) and (B), the court removes a major private-litigation pathway challenging state benefit design under “availability” and “comparability.” Future suits may be pushed toward administrative enforcement by HHS or alternative legal theories (where available).

2. Broader practical implications

  • State Medicaid discretion expands: States can more confidently defend categorical non-coverage of gender-dysphoria surgeries by emphasizing diagnosis-based plan design, cost constraints, and contested evidence on efficacy/necessity.
  • Record-building shifts to intent/pretext: Plaintiffs challenging such exclusions will likely need stronger evidence that the diagnosis line is a pretext for targeting transgender individuals (e.g., discriminatory legislative/administrative history) to escape rational-basis review.
  • Enforcement forum moves away from courts: With private causes of action curtailed under the Medicaid Act provisions invoked here, policy change may depend more on federal agency oversight, state political processes, and (if applicable) other statutes with clearer rights-creating language.

IV. Complex Concepts Simplified

  • Facial classification vs diagnosis-based regulation: A rule is “facially” discriminatory if it explicitly makes sex (or another protected trait) the condition for receiving a benefit. A diagnosis-based rule denies coverage for a procedure when used for a certain condition, regardless of who asks for it.
  • Proxy discrimination (pretext): A law that looks neutral can still be treated as discriminatory if the neutral category is used as a stand-in to target a protected group and the line is otherwise hard to explain on non-discriminatory grounds.
  • Rational basis review: The most deferential constitutional test. The government wins if there is any plausible legitimate reason for the policy, even if the court might think it unwise.
  • Intermediate scrutiny: A tougher test used for sex-based classifications, requiring a strong link between the classification and an important government interest. The court says it never gets here because it finds no sex classification.
  • Bostock “but-for” causation: Change one fact at a time. If changing sex changes the outcome, sex is a but-for cause. The court says changing sex does not change coverage if the diagnosis/use remains excluded.
  • Private cause of action / “rights-creating language”: Not every statutory requirement can be enforced by private plaintiffs in court. Under Medina/Gonzaga University v. Doe, the statute must clearly speak in terms of individual rights, not just state duties in a federal funding bargain.
  • Waiver vs forfeiture: Waiver is intentional giving up of an argument; forfeiture is a failure to raise it in time. Courts may sometimes consider forfeited issues, especially after an intervening Supreme Court decision.

V. Conclusion

Anderson v. Crouch operationalizes two recent Supreme Court decisions into a clear set of rules for Medicaid coverage litigation in the Fourth Circuit:

  • After United States v. Skrmetti, a state Medicaid plan’s exclusion of surgeries for treatment of gender dysphoria is not necessarily sex- or transgender-status discrimination; when framed as diagnosis-/use-based and unsupported by proof of pretext, it is reviewed under rational basis and can be justified by cost and contested medical evidence.
  • The same framing defeats ACA § 1557 sex-discrimination claims when, under Bostock as explained in Skrmetti, the but-for cause is the non-covered diagnosis/use rather than sex.
  • After Medina v. Planned Parenthood South Atlantic, plaintiffs lack a private cause of action to enforce Medicaid’s “availability” and “comparability” requirements—reorienting such disputes toward administrative enforcement and political processes rather than federal court injunctions.

In practical terms, the decision significantly narrows judicial avenues for challenging state Medicaid exclusions of gender-dysphoria surgeries and underscores a broader post-Medina retrenchment in private enforcement of Medicaid Act plan requirements.