In arguments over a state health plan’s gender-affirming care coverage exclusion, the full U.S. Court of Appeals for the Fourth Circuit went back and forth Thursday on issues of states’ rights and equal protection.

Chief Judge Albert Diaz and several other Democratic-appointed judges grilled the attorney for North Carolina’s health insurance plan on whether the plan treats transgender individuals differently from cisgender individuals by not paying for sex-reassignment surgeries and hormone treatments.

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