Dale Folwell, State Treasurer of North Carolina, et al. v. Maxwell Kadel, et al.

Like all health benefit plans, the North Carolina State Health Plan for Teachers and State Employees must make difficult choices about what treatments to cover. The Plan contains many exclusions, including for cosmetic services, experimental medications, and surgery for psychological reasons. This case concerns the Plan’s longstanding exclusion for treatments “leading to or in connection with sex changes or modifications and related care.” Respondents are individuals diagnosed with gender dysphoria. They filed this suit alleging that the Plan violated the Equal Protection Clause by refusing to cover drugs and surgeries they sought to treat that condition. A sharply divided en banc Fourth Circuit agreed. In doing so, the court not only doubled down on its view that transgender people are a “quasisuspect class,” but held that categorically refusing to cover sex-change treatments for anyone, no matter their sex, discriminates on the basis of sex. That decision reinforces two circuit splits and defies this Court’s repeated holdings that “regulation of a medical procedure that only one sex can undergo does not trigger heightened constitutional scrutiny unless the regulation is a ‘mere pretext designed to effect an invidious discrimination against members of one sex or the other.’” Dobbs v. Jackson Women’s Health Org., 597 U.S. 215, 236-37 (2022) (quoting Geduldig v. Aiello, 417 U.S. 484, 496 n.20 (1974)). The question presented is: Whether a State’s decision to decline to provide health benefit coverage for treatments leading to sex changes violates the Equal Protection Clause.