States have recently considered the extent to which transgender individuals should have access to certain medical treatments to address a discordance between a person’s sex characteristics and gender identity. While some states have enacted legislation ensuring that such services are available to transgender people, other states have policies restricting access to or otherwise limiting health coverage for them. Some of these restrictions are specific to minors, but others cover adults as well. For example, the West Virginia Medicaid program provides a blanket coverage exclusion for “transsexual surgery,” and North Carolina’s State Health Plan for Teachers and State Employees (NCSHP) categorically excludes coverage for treatments “leading to or in connection with sex changes or modifications.”The West Virginia Medicaid and NCSHP coverage exclusions, as well as other similar Medicaid and state health insurance coverage policies, have been challenged in federal court on the basis that the exclusions constitute sex discrimination in violation of the Fourteenth Amendment’s Equal Protection Clause and Section 1557 of the Patient Protection and Affordable Care Act (ACA), among other claims. District and appellate courts across the country considering similar coverage exclusions have arrived at different conclusions, disagreeing about the appropriate level of scrutiny to be applied. For example, a Wisconsin federal district court held that the state health plan’s exclusion of coverage for “surgery and sex hormones associated with gender reassignment” violated the Equal Protection Clause and Section 1557. (The parties agreed to voluntarily dismiss their cross-appeals to the Seventh Circuit.)