The downstream effects of the Supreme Court’s Skrmetti decision last year, affirming Tennessee’s ban on gender care for trans youth, continue to surface. In March, a U.S. appeals court ruling upheld a West Virginia ban on Medicaid funds for gender-affirming care for all ages, based on the Supreme Court’s reasoning.

The 4th U.S. Circuit Court of Appeals overturned a lower court decision that had reversed West Virginia’s ban, Michigan Advance reports. The lower court ruled that the state’s ban was discriminatory.

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Supreme Court’s anti-trans Skrmetti ruling was just used to protect a health care ban in Oklahoma

Like the Supreme Court, the 4th Circuit judges wrote that West Virginia’s policy applies only to certain procedures, contending it doesn’t target a protected class.

“It is not irrational for a legislature to encourage citizens ‘to appreciate their sex’ and not ‘become disdainful of their sex’ by refusing to fund experimental procedures that may have the opposite effect,” the three-judge panel wrote in its unanimous decision. “The Supreme Court’s decision in Skrmetti forecloses any argument to the contrary.”

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The plaintiffs in the case are seeking a rehearing by the full panel.

While the Supreme Court majority in Skrmetti characterized the decision as a straightforward matter of state authority over medical practice, divorced from arguments around transgender identity, West Virginia Gov. Patrick Morrissey (R) was explicit in connecting the two as he applauded the ruling.

“Today’s ruling makes clear that states have the authority to set reasonable limits within taxpayer-funded healthcare programs,” Gov. Morrisey said in March. “That principle matters as we continue defending common-sense laws that guide our country, protect women’s sports, and preserve safe spaces.”

Eleven states have enacted bans on Medicaid funding for gender-affirming care for trans people of all ages, with at least seven facing lawsuits, according to Reuters. The 4th Circuit decision puts the challenges to those laws in doubt.

Carmel Shachar, assistant clinical professor of law and faculty director of Harvard Law School’s Health Law and Policy Clinic, called the West Virginia ruling “a significant early case in the post-Skrmetti landscape.”

The ruling “is definitely influential,” she said, adding it’s “a sign of which way the wind is blowing right now when it comes to state policies.”

In Oklahoma, lawmakers advancing a ban even broader than West Virginia’s have that wind at their back following the 4th Circuit ruling.

Their legislation would prohibit Medicaid funds from covering adult gender-affirming care, and also bar public money from being used by any organization or individual to pay for gender transition.

That means that even a trans person with private medical insurance would be barred from gender-affirming care in a state-funded hospital. The bill passed 11-2 through a House oversight committee last week, after already being approved by the state Senate.

In August, a three-judge panel on the U.S. Court of Appeals for the 10th Circuit cited Skrmetti in its decision to reject a challenge to Oklahoma’s ban on gender-affirming healthcare for trans youth.

Oklahoma’s new bill is just the latest example of the ways Republicans are exploiting the Supreme Court’s ruling that gender-affirming care bans aren’t discriminatory. The West Virginia decision only helps advance an anti-trans agenda, said Shannon Minter, legal director at the National Center for LGBTQ Rights.

“It invites states to come up with creative ways to discriminate against other groups of people and disguise it as just regulation of medical care,” Minter said. “It’s dangerous when the law and the courts refuse to recognize that type of blatant discrimination.”

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