CHARLESTON, W.Va. (AP) — West Virginia's and North Carolina's refusal to cover certain health care for transgender people with government-sponsored insurance is discriminatory, a federal appeals court ruled Monday in a case likely headed to the U.S. Supreme Court.
The Richmond-based 4th U.S. Circuit Court of Appeals ruled 8-6 in the case involving coverage of gender-affirming care by North Carolina’s state employee health plan and the coverage of gender-affirming surgery by West Virginia Medicaid.
Specifically, North Carolina’s policy bars treatment or studies “leading to or in connection with sex changes or modifications and related care," while West Virginia’s bars coverage of “transsexual surgery.”
“The coverage exclusions facially discriminate on the basis of sex and gender identity, and are not substantially related to an important government interest,” Judge Roger Gregory, first appointed by former President Bill Clinton and re-appointed by former President George W. Bush, wrote in the majority opinion.
Similar cases are under consideration in courts across the country, but Monday's is the first U.S. Court of Appeals decision to consider government-sponsored coverage exclusions of gender affirming medical care — and whether those exclusions are lawful.
The ruling follows a decision earlier this month by 4th Circuit judges that West Virginia's transgender sports ban violates the rights of a teen athlete under Title IX, the federal civil rights law that prohibits sex-based discrimination in schools.
Like with the transgender sports law ruling, West Virginia Attorney General Patrick Morrisey said his office planned to appeal Monday's health care case decision.
“Decisions like this one, from a court dominated by Obama- and Biden-appointees, cannot stand: we’ll take this up to the Supreme Court and win,” Morrisey said in a statement.
North Carolina State Treasurer Dale Folwell, whose department oversees the state’s health plan, said in a news release that Monday’s majority decision was in “direct conflict” with other decisions from federal appeals courts and hopefully will be corrected by the U.S. Supreme Court.
Folwell said the State Health Plan is threatened by financial challenges as the plan’s member grows older and their health declines.
“Accordingly, the Plan cannot be everything for everyone,” Folwell said. “Untethered to the reality of the Plan’s fiscal situation, the majority opinion opens the way for any dissatisfied individual to override the Plan’s reasoned and responsible decisions and drive the Plan towards collapse.”
In the majority opinion, judges said the cost of treatment is not a sufficient argument to support upholding a policy found to be discriminatory.
“Especially where government budgets are involved, there will frequently be a ‘rational’ basis for discrimination,” Judge Gregory wrote.
Both states appealed separate lower court rulings that found the denial of gender-affirming care to be discriminatory and unconstitutional. Two panels of three Fourth Circuit judges heard arguments in both cases last year before deciding to intertwine the two cases and see them presented before the full court.
In June 2022, a North Carolina trial court demanded the state plan pay for “medically necessary services,” including hormone therapy and some surgeries, for transgender employees and their children. The judge had ruled in favor of the employees and their dependents, who said in a 2019 lawsuit that they were denied coverage for gender-affirming care under the plan.
The North Carolina state insurance plan provides medical coverage for more than 750,000 teachers, state employees, retirees, lawmakers and their dependents.
In August 2022, a federal judge ruled West Virginia’s Medicaid program must provide coverage for gender-affirming care for transgender residents.
An original lawsuit filed in 2020 also named state employee health plans. A settlement with The Health Plan of West Virginia Inc. in 2022 led to the removal of the exclusion on gender-affirming care in that company’s Public Employees Insurance Agency plans.
The states' lawyers argued that treatments for gender dysphoria — all treatments in North Carolina and surgical treatments in West Virginia — are excluded from coverage for everyone, regardless of their gender identity. They claimed only a subset of transgender people suffer from gender dysphoria, a diagnosis of distress over gender identity that does not match a person’s assigned sex.
Before offering pharmaceutical or surgical intervention, medical guidelines call for thorough psychological assessments to confirm gender dysphoria before starting any treatment.
In his opinion, Gregory said that in his view, gender dysphoria is “so intimately related to transgender status as to be virtually indistinguishable from it.”
“We hold that gender dysphoria, a diagnosis inextricable from transgender status, is a proxy for transgender identity,” the judge wrote. “And coverage exclusions that bar treatments for gender dysphoria bar treatments on the basis of transgender identity by proxy.”
Unlike North Carolina, West Virginia has covered hormone therapy and other pharmaceutical treatments for transgender people since 2017. Gregory noted that West Virginia’s program partially or fully covers surgeries to remove and reconstruct sexual organs for non-gender dysphoria-related diagnoses, such as cancer.
After the ruling, West Virginia plaintiff Shauntae Anderson, a Black transgender woman and West Virginia Medicaid participant, called her state's refusal to cover her care “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,” Anderson said in a statement.
FILE - Connor Thonen-Fleck addresses reporters while his parents stand by his side, March 11, 2019, in Durham, N.C. West Virginia and North Carolina's refusal to cover certain health care for transgender people with government-sponsored insurance is discriminatory, a federal appeals court ruled Monday, April 29, 2024 in a case likely headed to the U.S. Supreme Court. (AP Photo/ Jonathan Drew, FIle)
LOUISVILLE, Ky. (AP) — The cheers were endless Saturday in the PGA Championship, and when another record day of scoring finally ended at vulnerable Valhalla, so were the possibilities.
Xander Schauffele and Collin Morikawa were tied for the lead. Shane Lowry thrust his way into the mix with a 62 to tie a major championship record last set just two days earlier. Bryson DeChambeau chipped in for eagle on the last hole to set off a wild celebration.
And all Scottie Scheffler could do during all this chaos — at least it was inside the ropes this time — was listen to them.
Scheffler's remarkable streak of 42 consecutive rounds at par or better finally ended in the second-lowest scoring average for a Saturday at the PGA Championship. He faded early, never quite recovered and shot 73 to finish eight shots back with 23 players ahead of him.
“Too many mistakes,” Scheffler told CBS. He declined to speak to reporters. “I came out here hoping to have a good round and didn’t get it done.”
Schauffele, who opened the week with a 62 that felt easy, labored to stay in front and was two shots ahead until a 9-iron came out hot and sailed over the green at the 15th. With water on the other side of the green, he was careful with a chip out of shin-high grass and moved it 10 feet. He chipped on and two-putted for a double bogey, only his second hole over par this week.
Schauffele bounced back with two closing birdies for a 3-under 68.
Morikawa briefly took the lead with a 6-foot birdie putt that went 360 degrees around the cup before dropping on the 15th, and he holed a 10-foot birdie on the 18th for a 67 to tie Schauffele. They were at 15-under 198 with plenty of company.
Sahith Theegala birdied six of his last 10 holes for a 68 and was one shot behind. Another shot back was the trio of Lowry, DeChambeau (67) and Viktor Hovland (66) — a British Open champion, U.S. Open champion and FedEx Cup champion.
And it didn't stop there. Fifteen players were separated by five shots.
“There are a ton of guys who can do it tomorrow,” Morikawa said.
The shocker was Scheffler not being among them.
Scheffler was coming off the most heart-racing day of his career that featured an arrest for not following police orders, brief jail time and a 66 to get into contention for a second straight major. But he was never a factor after an early stretch of double bogey-bogey-bogey.
“I definitely did not feel like myself today,” he said. “Yesterday happened, I did my best to recover from it and come out and compete. This morning was not my usual routine for a round. At the end of the day, I came out hoping to have a good round but I wasn’t able to get it done, which was frustrating.”
Even at the home of the Kentucky Derby, this final round could be tough to handicap.
Lowry's magnificent performance — he made 161 feet worth of putts — ended with a wedge to just inside 12 feet and a clear shot at 61, only to not give the putt enough pace.
“Probably the most disappointed anyone can ever be shooting 62,” Lowry said. “Look, I went out there with a job to do today, and my job was to try to get myself back in the tournament. And I definitely did that.”
DeChambeau had only three birdies and didn't get much out of his round until he chipped in for his eagle, a moment so loud it was hard to tell if he or the thousands of fans were more excited. He said he hasn't felt that kind of energy since his 58 to win LIV Golf Greenbrier last year.
“Exhilarating,” he said. “That was pretty exciting there. I was pretty pumped. I’ve got a good chance. I’m not executing to the level that I know I can, but playing well enough to give myself a chance, obviously.”
Justin Rose (64) was three shots back. The group five behind at 10-under 203 included Justin Thomas, the Louisville native who felt chills on a steamy day of sunshine when he hacked out of the weeds, down to the green and into the cup on the par-3 14th for a most unlikely birdie. He shot 67.
That's 15 players at 10 under or better, the most through 54 holes in major championship history. The previous record was seven players, most recently at St. Andrews in 2022.
The scoring average for the third round was 69.55, a fraction behind the record for the PGA Championship set at Bellerive in 2018.
This was the day to go low just to stay in the hunt. Scheffler, using fill-in caddie with regular looper Ted Scott attending his daughter's high school graduation in Louisiana, was in trouble from the start — a double bogey on No. 2 from mangled rough, a tee shot into a hazard left of the reachable par-4 fourth hole.
He was 4 over through four holes, and on three occasions he followed a birdie with a bogey. It was his highest score since a 73 in the third round of the Tour Championship last August.
Now the focus turns to Schauffele, the Olympic gold medalist from the Tokyo Games in 2021 who is trying to bag a silver prize — the heavy Wanamaker Trophy — for his first major. Schauffele has been leading or tied in six of his last seven rounds.
The exception was losing a 54-hole lead last week to Rory McIlroy's closing 65 at Quail Hollow.
“I just need to stay in my lane, and hopefully it's enough,” Schauffele said.
Morikawa already had two majors at age 24 and is slowly working his way back to that smooth, repeatable swing. He had one early wobble missing a 4-foot par putt on the second hole, and that was really his only big mistake.
There was no shortage of candidates to claim the second major of the year. It was crowded at the top, just like it was at Harding Park in 2020, when a dozen players were separated by three shots going into the final round. Morikawa emerged with his first major.
“Look, I’ve played against all these guys. It’s not like any of these guys are new,” Morikawa said. “They all have their accolades within themselves, and really anyone can go low.”
AP golf: https://apnews.com/hub/golf
Xander Schauffele hits from the fairway on the 17th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Jeff Roberson)
Sahith Theegala waves after making a putt on the 18th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Sue Ogrocki)
Sahith Theegala reacts to his shot from the fairway on the 18th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Jeff Roberson)
Bryson DeChambeau celebrates after a eagle on the 18th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Sue Ogrocki)
Bryson DeChambeau celebrates after a eagle on the 18th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Sue Ogrocki)
Shane Lowry, of Ireland, celebrates after a birdie on the 13th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Matt York)
Justin Rose, of England, greets Shane Lowry, of Ireland, after the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Jeff Roberson)
Scottie Scheffler reacts to his chip to the green on the fourth hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Jeff Roberson)
Scottie Scheffler waits to play on the second hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Jeff Roberson)
Collin Morikawa hits from the fairway on the 18th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Jeff Roberson)
Collin Morikawa waves after making a putt on the 18th hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Sue Ogrocki)
Xander Schauffele watches his tee shot on the fourth hole during the third round of the PGA Championship golf tournament at the Valhalla Golf Club, Saturday, May 18, 2024, in Louisville, Ky. (AP Photo/Matt York)
