Missouri Upholds SAFE Act and Medicaid Funding Ban Under Rational-Basis Review as Age-and-Medical-Use Classifications

Case: E.N. v. Kehoe (Supreme Court of Missouri, Jan. 13, 2026)

Holding in brief: Facial challenges to Missouri’s SAFE Act and Medicaid funding ban fail; both measures are reviewed under rational-basis scrutiny because they classify by age and medical use (purpose), not by sex or transgender status, and they do not infringe a fundamental right.

1. Introduction

In E.N. v. Kehoe, the Supreme Court of Missouri affirmed a circuit court judgment upholding two 2023 enactments: (1) the “SAFE Act,” which generally prohibits health care providers from performing gender transition surgeries on minors and from prescribing or administering cross-sex hormones or puberty-blocking drugs to minors “for the purpose of assisting gender transitions,” subject to specified exemptions and a sunset provision for certain drug restrictions; and (2) a “Medicaid ban,” which precludes MO HealthNet payments for those same interventions when provided “for the purpose of a gender transition.”

The Challengers brought multiple pre-enforcement claims under the Missouri Constitution. The issues central to the appeal were whether the SAFE Act and the Medicaid ban violate (a) equal protection (Mo. Const. art. I, sec. 2), (b) due process (Mo. Const. art. I, sec. 10), and (c) the “gains of industry” clause (Mo. Const. art. I, sec. 2), and whether alleged evidentiary errors undermined the circuit court’s judgment after a two-week bench trial.

2. Summary of the Opinion

The Court affirmed across the board. It held:

  • Nature of challenge: Challengers raised only facial challenges, seeking to invalidate the statutes “in their entireties,” triggering the demanding standard that they must show “no set of circumstances” under which the statutes would be valid.
  • Equal protection: The SAFE Act does not classify based on sex or transgender status; it classifies by age and medical use/purpose. Therefore, rational-basis review applies, and the Act is rationally related to the legitimate interest of safeguarding minors amid medical uncertainty.
  • Due process: No fundamental right exists for parents to obtain for minors a treatment the legislature deems inappropriate, nor for minors to obtain prohibited treatments. With no fundamental-right infringement, rational-basis review applies; the SAFE Act survives for the same reasons as under equal protection.
  • Gains of industry: The clause does not apply to allegedly “otherwise lawful” care where the Court has upheld the underlying prohibition; and the Medicaid ban merely limits public payment rather than prohibiting care or compelling uncompensated work.
  • Medicaid ban: The ban classifies only by medical use/purpose and does not infringe a fundamental right. Rational-basis review applies, and the State’s interests in policy choice and fiscal stewardship—coupled with uncertainty and lack of accepted standards—are sufficient.
  • Evidentiary/factual disputes: Even if contested, they do not change the outcome because rational-basis review requires only a “reasonably conceivable” factual basis for the classification.

The Court also overruled as moot Challengers’ motion to strike portions of Respondents’ exhibit list and exhibits.

3. Analysis

3.1 Precedents Cited

The opinion is notably structured around two types of authority: (1) Missouri cases governing constitutional review, burdens, and facial/as-applied framing; and (2) recent federal cases upholding similar laws and, in effect, supplying the doctrinal template for classifying the statutes and selecting rational-basis review.

A. Missouri constitutional review, burdens, and framing

  • State v. Wooden, 388 S.W.3d 522 (Mo. banc 2013), and St. Louis Cnty. v. Prestige Travel, Inc., 344 S.W.3d 708 (Mo. banc 2011): establish de novo review for constitutional validity, a strong presumption of constitutionality, and the challenger’s burden to show a statute “clearly contravene[s]” the constitution.
  • Donaldson v. Mo. State Bd. of Registration for the Healing Arts, 615 S.W.3d 57 (Mo. banc 2020), and State v. Perry, 275 S.W.3d 237 (Mo. banc 2009): provide the rigorous facial-challenge standard (“no set of circumstances exists”) and emphasize that facial challenges are the most difficult to win.
  • F.S. v. Mo. Dep't of Corr., Div. of Prob. & Parole, 709 S.W.3d 321 (Mo. banc 2025), and State v. Collins, 648 S.W.3d 711 (Mo. banc 2022): frame how Missouri distinguishes facial from as-applied challenges—by claim nature, remedy sought, and analysis required. The Court used these to conclude Challengers sought only total invalidation, confirming facial posture.
  • State v. Young, 362 S.W.3d 386 (Mo. banc 2012): supplies the baseline that Missouri’s equal protection clause provides the same protections as federal equal protection, and sets out the two-step equal protection analysis (select scrutiny, then apply it).
  • Amick v. Dir. of Revenue, 428 S.W.3d 638 (Mo. banc 2014), and Estate of Overbey v. Chad Franklin Nat'l Auto Sales N., LLC, 361 S.W.3d 364 (Mo. banc 2012): emphasize the deferential character of rational-basis review and that courts uphold statutes if any plausible/“reasonably conceivable” facts justify the classification.
  • Doe v. Olson, 696 S.W.3d 320 (Mo. banc 2024): reinforces that rational basis can be satisfied without an express legislative statement of purpose if any set of facts can reasonably be conceived to justify the law.
  • Fisher v. State Highway Comm'n of Mo., 948 S.W.2d 607 (Mo. banc 1997): narrows the “gains of industry” clause, noting its typical association with workplace slavery and observing it has been invoked only once to challenge a ban on selling a lawful product—limiting its expansion to the medical-regulation context here.

B. Federal and sister-circuit authorities shaping scrutiny selection and merits

  • United States v. Skrmetti, 605 U.S. 495 (2025), and Brandt ex rel. Brandt v. Griffin, 147 F.4th 867 (8th Cir. 2025): the Court treated these as persuasive and central. They supply (i) the “age + medical use/purpose” characterization, (ii) the “lack of identity” reasoning between transgender status and the excluded diagnoses/purposes, and (iii) the conclusion that rational-basis review is appropriate for analogous bans on puberty blockers/hormones for gender transition in minors.
  • Bray v. Alexandria Women's Health Clinic, 506 U.S. 263 (1993): invoked by Challengers for the proposition that discriminatory purpose may be presumed when a law targets a protected class; the Court rejected its applicability because it found no sex/transgender classification on the statute’s face.
  • New York v. Ferber, 458 U.S. 747 (1982): provides the oft-quoted legitimate interest in safeguarding “the physical and psychological well-being of a minor,” supporting the State’s justification under rational basis.
  • Romer v. Evans, 517 U.S. 620 (1996), and Gallagher v. City of Clayton, 699 F.3d 1013 (8th Cir. 2012): appear in the amici/animus discussion. The Court used Gallagher to confine Romer-type “animus-only” invalidation to cases where no legitimate interest survives scrutiny.
  • Washington v. Glucksberg, 521 U.S. 702 (1997), Troxel v. Granville, 530 U.S. 57 (2000), and Comm. for Educ. Equal. v. State, 294 S.W.3d 477 (Mo. banc 2009): anchor the substantive due process framework—fundamental rights must be deeply rooted; if a fundamental right is implicated, strict scrutiny applies.
  • Cruzan by Cruzan v. Harmon, 760 S.W.2d 408 (Mo. banc 1988): cited for autonomy in health decisions, but distinguished as not extending to minors seeking legislatively prohibited treatments.
  • Danker v. City of Council Bluffs, 53 F.4th 420 (8th Cir. 2022): used for the proposition that a rational basis sufficient for equal protection typically suffices for substantive due process.
  • Hooper v. Bernalillo Cnty. Assessor, 472 U.S. 612 (1985): cited for the baseline that absent protected-class categorization or fundamental-right infringement, rational-basis review applies.
  • Weaver v. Reagen, 886 F.2d 194 (8th Cir. 1989), and Smith v. Rasmussen, 249 F.3d 755 (8th Cir. 2001): frame Medicaid “medical necessity” disputes as constrained by state discretion to set standards for the extent of medical assistance.
  • Dobbs v. Jackson Women's Health Org., 597 U.S. 215 (2022): cited for the idea that courts may recognize some areas as “fraught with medical and scientific uncertainties,” supporting legislative latitude.
  • Maher v. Roe, 432 U.S. 464 (1977): supplies a key Medicaid-funding principle—states have legitimate interests in allocating limited public funds, and funding choices can reflect policy judgments where opinions are sharply divided.
  • McNeil-Terry v. Roling, 142 S.W.3d 828 (Mo. App. 2004), and its cited authorities Cushion v. Dep't of PATH, 807 A.2d 425 (Vt. 2002), and Curtis v. Taylor, 625 F.2d 645 (5th Cir. 1980): referenced to situate fiscal restrictions in Medicaid as permissible when they do not undermine the program’s purpose—particularly where excluded services are not medically necessary.

3.2 Legal Reasoning

A. The Court’s threshold move: locking the case into facial review

The opinion’s first decisive step is procedural but outcome-shaping: by classifying Challengers’ claims as facial, the Court raised the bar to the “no set of circumstances” standard (Donaldson v. Mo. State Bd. of Registration for the Healing Arts). The Court relied heavily on the remedies sought—total invalidation and broad non-enforcement—to conclude that even if individual hardships existed, they were not presented as as-applied claims (F.S. v. Mo. Dep't of Corr., Div. of Prob. & Parole; State v. Collins).

This framing matters: rational-basis review is already deferential, and facial posture further reduces the plaintiff’s ability to prevail by pointing to allegedly unconstitutional applications, contested facts, or individual medical circumstances.

B. Equal protection: defining the classification to determine scrutiny

The core equal-protection fight was over how to characterize the statutes’ classification. Challengers asserted classification by sex and transgender status (potentially triggering heightened scrutiny). The Court adopted the United States v. Skrmetti / Brandt ex rel. Brandt v. Griffin framing: the SAFE Act distinguishes by age (minors) and medical use/purpose (gender transition purpose vs other therapeutic purposes allowed via exemptions).

The Court also rejected heightened scrutiny based on alleged discriminatory purpose. Using Skrmetti’s “lack of identity” logic, the Court reasoned that although only transgender minors seek these drugs/surgeries for the excluded purpose, the statute still sorts patients by purpose/diagnosis rather than “transgender status” as a legal category. Put differently, overlap is not identity; the statute removes “one medical purpose” from the permissible range rather than excluding persons as such.

Once rational-basis review was selected, the Court asked only whether plausible reasons exist. It found the State’s interest in protecting minors amid genuine medical/ethical debate and uncertainty to be legitimate (New York v. Ferber), and the ban to be rationally related to that interest (Skrmetti).

C. Due process: no fundamental right to obtain prohibited treatment for minors

The due process analysis tracked the opinion’s equal-protection architecture. Challengers relied on parental rights (Troxel v. Granville) and bodily autonomy concepts (Cruzan by Cruzan v. Harmon) to claim fundamental rights to access gender-transition-related care.

The Court accepted the general proposition that parents have rights concerning care and custody, but adopted the Eighth Circuit’s narrower formulation from Brandt ex rel. Brandt v. Griffin: there is no fundamental right for a parent to obtain for a child a treatment the legislature deems inappropriate for minors, even if a child desires it and a doctor approves it. Similarly, the Court did not extend Cruzan by Cruzan v. Harmon to create a minor’s fundamental right to receive a legislatively prohibited treatment.

With no fundamental right recognized, the Court applied rational-basis review and then relied on Danker v. City of Council Bluffs to treat the equal-protection rational basis as effectively dispositive of the substantive due process claim as well.

D. “Gains of industry”: keeping an unusual clause in its narrow lane

The Court treated the gains of industry clause as historically limited and rarely successful (Fisher v. State Highway Comm'n of Mo.). Two doctrinal moves are important:

  • Because the SAFE Act’s prohibitions were upheld, the Court treated the proscribed care as not “otherwise lawful” for gains-of-industry purposes—undercutting the theory that providers were being blocked from pursuing lawful work.
  • As to Medicaid, the Court stressed the funding ban does not prohibit care and does not compel providers to work without payment; it simply bars MO HealthNet reimbursement.

E. Medicaid ban: payment restrictions as policy choices under deferential review

For the Medicaid ban, the Court again emphasized classification by medical use/purpose and the absence of a protected-class categorization or fundamental-right infringement, thus applying rational basis (Hooper v. Bernalillo Cnty. Assessor).

The Court also signaled that even “medically necessary” arguments do not eliminate state discretion: while Medicaid plans must align with the Medicaid Act’s objectives (Weaver v. Reagen), states retain “broad discretion” to adopt standards for the extent of medical assistance (Smith v. Rasmussen). The Court then added two rational bases: (1) uncertainty and lack of accepted standards of practice (invoking Dobbs v. Jackson Women's Health Org.), and (2) fiscal stewardship and value-laden policy judgments about public funding (Maher v. Roe).

F. Evidence disputes: de-emphasized by the logic of rational basis + facial posture

Challengers argued expert-qualification errors and unsupported factual findings. The Court’s response was structural: because rational basis allows courts to uphold a statute if any reasonably conceivable facts support it (Estate of Overbey v. Chad Franklin Nat'l Auto Sales N., LLC), and because the Court found a rational basis “on the record before this Court,” contested evidentiary details could not change the result. This is a common practical effect of deferential scrutiny—factual skirmishes rarely matter once the court deems the legislature’s policy judgment “plausible.”

3.3 Impact

1) Missouri aligns state constitutional analysis with the post-2025 federal template. By expressly treating Missouri equal protection as coextensive with federal equal protection (State v. Young) and by leaning on United States v. Skrmetti and Brandt ex rel. Brandt v. Griffin, the decision signals that challenges to similar regulations in Missouri will likely be evaluated through the same “age + medical use/purpose” lens, making heightened scrutiny difficult to obtain.

2) Procedural pleading/relief choices become decisive. The Court’s insistence that the requested relief sought total invalidation effectively foreclosed as-applied nuance. Future litigants challenging medical regulations in Missouri may attempt narrower, plaintiff-specific claims to avoid the “no set of circumstances” barrier and to force the court into application-sensitive analysis.

3) “Animus” arguments face a higher threshold when any plausible child-welfare or uncertainty rationale exists. The Court’s reliance on Gallagher v. City of Clayton to cabin Romer v. Evans suggests Missouri courts may reject animus theories whenever the State can articulate (or the court can conceive) a legitimate interest that plausibly fits the law.

4) Medicaid funding restrictions will be difficult to overturn absent a clearer statutory or constitutional hook. The Court treated the Medicaid ban primarily as a funding allocation decision, where Maher v. Roe-style fiscal and policy reasoning is especially influential. Plaintiffs may need to pivot toward statutory Medicaid compliance claims (where available) rather than relying mainly on state constitutional equal protection/due process.

5) “Gains of industry” remains narrow. By reaffirming Fisher v. State Highway Comm'n of Mo.’s constrained view, the Court discourages using the clause as a broad economic-liberty weapon against health and safety regulation—particularly where the underlying conduct has been declared unlawful.

4. Complex Concepts Simplified

  • Facial vs. as-applied challenge: A facial challenge argues a law is unconstitutional in all its applications—so the entire law must fall. An as-applied challenge argues the law is unconstitutional when applied to a particular person or situation—so only that application is blocked. Facial challenges are harder because the challenger must show the law can never be valid.
  • Levels of scrutiny (equal protection / due process): Courts choose how strictly to review a law. Strict scrutiny is hardest for the government to pass (usually for suspect classifications or fundamental rights). Intermediate scrutiny often applies to sex-based classifications. Rational-basis review is most deferential: the law stands if it is reasonably related to any legitimate government interest.
  • “Classifies by medical use/purpose”: Instead of treating “who you are” (e.g., sex, race) as the legal category, the statute is treated as distinguishing “what the treatment is for.” Here, the Court viewed the statutes as permitting certain drugs/surgeries for some conditions but not “for the purpose of a gender transition.”
  • “Invidious discriminatory purpose” / “animus”: Even if a law is facially neutral, it can trigger heightened scrutiny if enacted with a discriminatory purpose. But the Court treated animus arguments as insufficient where a plausible legitimate interest (protecting minors amid uncertainty) exists.
  • Substantive due process “fundamental rights”: Some liberties are protected so strongly that the government must meet strict scrutiny to restrict them. The Court held that parental rights and bodily autonomy do not extend to a fundamental right to obtain for minors a treatment the legislature has prohibited.
  • Medicaid funding vs. medical prohibition: A funding ban does not necessarily forbid a medical procedure; it can simply mean the state will not pay for it. The Court emphasized this distinction for adult claims: adults remain free to seek the care, but MO HealthNet will not reimburse it.

5. Conclusion

E.N. v. Kehoe cements a Missouri constitutional framework for evaluating restrictions on minors’ access to gender-transition-related interventions and state Medicaid reimbursement for such interventions: by defining the laws as age-and-medical-use classifications, the Court avoided heightened scrutiny and upheld both measures under highly deferential rational-basis review. The decision’s practical significance lies as much in its procedural and analytic choices—facial framing, coextensive state/federal equal protection, and reliance on United States v. Skrmetti and Brandt ex rel. Brandt v. Griffin—as in its substantive conclusions, making future statewide invalidation efforts in Missouri difficult absent a shift in doctrine, a materially different statutory design, or narrower as-applied litigation.