A court decision on Medicaid coverage in West Virginia could further undermine access to gender-affirming health care for trans adults. The 4th U.S. Circuit Court of Appeals became the first federal appellate court to uphold a Medicaid ban on coverage for surgeries for transgender adults, less than a year after the Supreme Court's ruling allowing a Tennessee ban on such care. The panel ruled that West Virginia’s Medicaid exclusions do not discriminate against transgender people, but only specific surgical procedures to alleviate gender dysphoria. Critics argue that this could set up a precedent for future legal challenges.